burns (5)
An escharotomy must be performed in a client admitted for burns. Which statement accurately describes this procedure? 1 An incision is made through the burn eschar. 2 Anesthesia is administered to the client for pain. 3 Analgesia is not administered with this procedure. 4 The procedure is performed in the surgical suite
1. An incision is made through the burn eschar. Rationale: Escharotomy is a surgical procedure that is performed to treat inadequate tissue perfusion in the client with severe burns. In this procedure, an incision is made through the burn eschar. It helps to relive the pressure caused due to fluid accumulation near the chest and improves circulation. It is not necessary to administer anesthesia to the client as the nerve endings are destroyed due to the injury. The client is given sedation and analgesia to reduce anxiety. Although escharotomy is a surgical procedure, it is often performed in a treatment room.
Good A client with 32% total body surface area burns has a hematocrit of 54% 10 hours after the burn injury and 8 hours after fluid resuscitation was started. What is the nurse's best action? 1 Assess the client's blood pressure and urine output. 2 Notify the health care provider immediately. 3 Evaluate the client's electrocardiogram for dysrhythmias. 4 Increase the IV infusion rate
1. Assess the client's blood pressure and urine output. Rationale: The massive fluid shift causes hemoconcentration of the cells in the blood. The first action needed is to evaluate the adequacy of the fluid resuscitation by assessing the client's blood pressure and hourly urine output. If fluid resuscitation is adequate, no other action is needed. If blood pressure and urine output indicate fluid resuscitation at the current rate is not adequate, the health care provider should be called and resuscitation volumes may be increased.
Good The nurse is reviewing a medication record for an older adult client recently admitted to the burn unit with severe burns to the upper body from a house fire. The nurse plans to contact the health care provider if the client is receiving which medication? 1 Furosemide (Lasix) 2 Digoxin (Lanoxin) 3 Dopamine (Inotropin) 4 Morphine sulfate
1. Furosemide (Lasix) Rationale: Furosemide, a diuretic, generally is not given to improve urine output for burn clients. Diuretics decrease circulating volume and cardiac output by pulling fluid from the circulating blood to enhance diuresis. This reduces blood flow to other vital organs. Digoxin may be used to strengthen the force of myocardial contractions in older adult clients. Dopamine may be given to increase cardiac output in older adult clients. Morphine sulfate may be indicated for pain management.
A client with partial-thickness burns of the face and chest caused by a campfire is admitted to the burn unit. The nurse plans to carry out which health care provider request first? 1 Give oxygen per nonrebreather mask at 100% Fio2. 2 Infuse lactated Ringer's solution at 150 mL/hr. 3 Give morphine sulfate 4-10 mg IV for pain control. 4 Insert a 14 Fr retention catheter.
1. Give oxygen per nonrebreather mask at 100% Fio2. Rationale: Facial burns are frequently associated with upper airway inflammation. Administration of oxygen will assist in maintaining the client's tissue oxygenation at an optimal level. Although fluid hydration and pain control are important, the nurse's first priority is the client's airway. Monitoring output is important, but the nurse's first priority is the client's airway.
Which electrolyte abnormality does the nurse anticipate during the resuscitation phase in a client with burn injury? 1 Hyperkalemia 2 Hypernatremia 3 Hypochloremia 4 Hypoglycemia
1. Hyperkalemia Rationale: Hyperkalemia may occur during the resuscitation phase of burn injury because of the tissue destruction, disruption of the sodium-potassium pump, and red blood cell hemolysis. Hyponatremia (not hypernatremia), hyperchloremia (not hypochloremia), and hyperglycemia (not hypoglycemia) may also occur.
Real good explanation A client who was successfully resuscitated after a burn injury begins diuresis 3 days after admission. For which assessment findings does the nurse observe during this phase of the injury? Select all that apply. 1 Hyponatremia 2 Hyperkalemia 3 Hypotension 4 Weight gain 5 Metabolic acidosis 6 Metabolic alkalosis
1. Hyponatremia 3. Hypotension 5. Metabolic acidosis Rationale: Fluid remobilization starts at about 24 hours postinjury and the diuretic phase begins at about 48-72 hours after burn injury. Interstitial fluids mobilize and diuresis results in hypotension, hyponatremia, hypokalemia, weight loss, and possible metabolic acidosis from loss of bicarbonate in the urine and increased metabolism.
A client with full-thickness burns to the lower extremities has had emergent fasciotomies. What assessment parameter does the nurse monitor to evaluate the effectiveness of the fasciotomies? 1 Improved distal pulses 2 Reduced edema 3 Improved blood pressure 4 Reduced fluid resuscitation needs
1. Improved distal pulses Rationale: When edema is severe under the eschar of a full-thickness wound, blood flow to the area is compromised. Incisions, escharotomies, or fasciotomies are performed to relieve the growing pressure under the eschar. After the escharotomy or fasciotomy is performed, the assessment of improved perfusion is achieved by evaluating pulses distal to the procedure. Edema may not be reduced immediately due to inflammation from the incision. Blood pressure may be slightly elevated secondary to discomfort following the procedure. A fasciotomy does not necessarily indicate that fluid resuscitation will no longer be required.
A client with a severe burn injury is prescribed gentamicin sulfate (Gentamar). Which nursing intervention is most appropriate related to this medication? 1 Monitoring creatinine clearance 2 Administering a pain medication 3 Evaluating white blood cell count 4 Assessing the wound for infection
1. Monitoring creatinine clearance Rationale: Gentamicin sulfate (Gentamar) is a medication prescribed to decrease the risk for infection for clients who have suffered a severe burn injury. While administering this medication to a client, it is essential that the nurse monitor the client's creatinine clearance because this drug can adversely affect kidney function and cause nephrotoxicity. Although the nurse would administer pain medication, evaluate white blood cell count, and monitor this client for wound infection, these are not interventions that are needed while administering gentamicin sulfate.
The nurse is caring for a client with a burn injury who is receiving sulfadiazine (Silvadene) to the burn wounds. Which best describes the goal of topical antimicrobials? 1 Reduction of bacterial growth in the wound and prevention of systemic sepsis 2 Prevention of cross-contamination from other clients in the unit 3 Enhanced cell growth 4 Reduced need for a skin graft
1. Reduction of bacterial growth in the wound and prevention of systemic sepsis Rationale: Topical antimicrobials such as sulfadiazine are an important intervention for infection prevention in burn wounds. Topical antimicrobials such as sulfadiazine do not prevent cross-contamination from other clients in the unit. They do not enhance cell growth nor do they minimize the need the need for a skin graft.
A client who was rescued from an explosion is provided fluid resuscitation. Which factor should be assessed in the client after providing fluid resuscitation? 1 Serum sodium levels 2 Hemoglobin levels 3 Alanine aminotransferase 4 Serum cholesterol levels
1. Serum sodium levels Rationale: Renal failure is caused due to the accumulation of large amounts of proteins and myoglobin in the kidneys as a result of muscle damage. Fluid resuscitation must be provided to the client in order to maintain a rate of 30 to 50 mL of urine output. Serum sodium levels, serum creatinine levels, and specific gravity of the urine must be monitored every hour after providing fluid resuscitation to the client—it helps to assess kidney function. Hemoglobin levels can be monitored in case of anemia; hemoglobin levels are not an indicator of kidney function. Alanine aminotransferase is an enzyme that is secreted by the liver and is an indicator of hepatic functioning.
Good An older client has suffered a 45% body surface area burn from a house fire. Which complication is the client at greater risk of developing because of age-related changes? 1 Ineffective pain management 2 Acute kidney injury 3 Anxiety 4 Gastric stress ulcers
2. Acute kidney injury Rationale: The older client is at greater risk of developing shock and acute kidney injury after a burn injury because resuscitation efforts may be limited due to underlying cardiac dysfunction that occurs with aging. Ineffective pain management, anxiety, and gastric stress ulcers can occur in any client with a burn injury.
Which assessment does the nurse perform first on a client who has been admitted after an electrical injury with contact sites on the right hand and left foot? 1 Oxygen saturation 2 Electrocardiography 3 Depth of burn injury 4 Urine output
2. Electrocardiography Rationale: With contact sites on the right hand and foot, the current traveled in all body tissues between these two areas, with the potential to damage any tissue in the pathway. The heart is in this pathway and can suffer extensive damage to the muscle and the conduction system. Continuous electrocardiography (ECG) monitoring to determine heart health is the most important of the assessment areas listed.
Good A client with an electrical burn is being resuscitated with fluids. The nurse reports a decrease in urine output from 50 mL/hr to 15 mL/hr. Which order does the nurse question? 1 500-mL fluid bolus 2 Furosemide 40 mg IV 3 Increase IV fluids by 100 mL/hr for 4 hours 4 Send urinalysis for myoglobin
2. Furosemide 40 mg IV Rationale: A common mistake in treatment for burn injury is administering diuretic agents during the fluid resuscitation phase in an effort to increase urine output. A reduction in urine output is usually the result of decreased perfusion. The appropriate intervention is to increase fluid resuscitation to improve renal perfusion and subsequent urine output. Sending a urinalysis for myoglobin is important because myoglobin levels are elevated in clients with electrical burns and can cause renal damage in large amounts.
Good The nurse is reviewing the orders for a client admitted with 25% body surface area burns. Which order does the nurse clarify with the health care provider? 1 Daily weights 2 Hold omeprazole (Prilosec) 3 Fentanyl (Actiq) 50 mcg IV every 4 hours PRN for pain 4 Activity as tolerated
2. Hold omeprazole (Prilosec) Rationale: The nurse should question the order to hold omeprazole, a proton pump inhibitor agent. Clients with burn injury are at increased risk of developing an acute gastroduodenal ulcer (Curling's ulcer) within the first 24 hours after a severe burn injury because of reduced blood flow to the gastrointestinal tract and mucosal lining damage. Proton pump inhibitors and H2-histamine blocking agents along with early enteral feedings are important interventions to prevent this complication. Daily weights, IV opioid agents for pain management, and activity orders are appropriate for clients with burn injuries.
A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client? 1 Intramuscular 2 Intravenous 3 Sublingual 4 Topical
2. Intravenous Rationale: During the resuscitation postburn phase, the intravenous route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. Because the skin is too damaged, the sublingual route and the topical route are not indicated for administering drugs to the client in the resuscitation phase of burn injury.
A client with burns to the face, neck, upper body, and hands from a house fire starts wheezing on exhalation and reports difficulty swallowing about 4 hours after the injury. What is the nurse's best first action? 1 Ensure that the client remains NPO. 2 Notify the Rapid Response Team. 3 Slow the IV infusion rate. 4 Raise the head of the bed.
2. Notify the Rapid Response Team. Rationale: The client is at high risk for an inhalation injury from the circumstances of the burn (enclosed space and burns to the face, neck, upper body, and hands). The wheezing and difficulty swallowing indicate possible pulmonary injury and oral and throat swelling. This client is in danger of losing a patent airway and needs emergency intubation immediately.
A client with burns has developed sepsis. Which sign or symptom in the client indicates fungal infection? 1 Severe disorientation 2 Occasional diarrhea 3 Hypothermia 4 Lethargy
2. Occasional diarrhea Rationale: Sepsis, often present due to open burn wounds, can be caused due to fungi, gram-positive bacteria, and gram-negative bacteria. Signs and symptoms of fungal infection are the presence of occasional diarrhea, mild disorientation, and fever. Severe disorientation and lethargy are symptoms of gram-positive bacterial infection. Hypothermia is a symptom of gram-negative bacterial infection.
A client arrives in the emergency department with burns as a result of spilling boiling water while cooking. Which assessment finding of the burned areas on the tops of both hands and chest does the nurse use as a basis to document a probable full-thickness injury? 1 Most of the wounded area is red. 2 Thrombosed blood vessels are visible beneath the skin surface. 3 The area does not blanch when firm pressure is applied. 4 The client reports that the area hurts when touched.
2. Thrombosed blood vessels are visible beneath the skin surface. Rationale: The presence of thrombosed blood vessels beneath the skin surface is a strong indication of a full-thickness injury. Partial-thickness injuries can directly damage more superficial blood vessels, but do not cause thrombosis of deeper vessels. Red areas can be associated with nearly any depth of burn injury. The presence of pain is not a good indicator of burn depth. Although full-thickness injuries have much less pain than partial-thickness injuries, pain may still be present. Deep partial-thickness injuries may or may not blanch with firm pressure.
Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury? 1 Pale, boggy, dry, or crusted granulation tissue 2 Increasing wound drainage 3 Scar tissue formation 4 Sloughing of grafts
3. Scar tissue formation Rationale: Indicators of wound healing include the presence of granulation, reepithelization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.
Good (same info in powerpoint) Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury? 1 Bowel sounds 2 Muscle strength 3 Signs of infection 4 Urine output
3. Signs of infection Rationale: The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are not the priority during the acute phase of burn injury.:
A client has a 32% burn injury to the chest, arms, and legs with the following assessment data. After reviewing the assessment data, the nurse contacts the provider to evaluate the client for the possible development of which potential complication associated with burn injury? Data: RR 32, Temp 101.5, HR 110, BP 110/62, urine output<30mL/hr, BG 220 vomiting x1, pt alert, anxious, wounds converted from partial thickness to full thickness in some areas, increased burn wound drainage 1 Acute respiratory distress syndrome 2 Hypovolemic shock 3 Systemic infection 4 Acute kidney injury
3. Systemic infection Rationale: Burn-injured clients are at increased risk of local and systemic infection. Signs of infection include elevated temperature, tachycardia, tachypnea, decreased blood pressure, hyperglycemia, decreased gastric function, altered mental status, and the conversion of burn wounds to include increased drainage and poor healing. Acute respiratory distress syndrome, hypovolemic shock, and acute kidney injury are potential complications for burn-injured clients, but the assessment data in the client's chart do not indicate these conditions.
Good The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement? 1 Blood urea nitrogen (BUN), 36 mg/dL 2 Creatinine, 2.8 mg/dL 3 Urine output, 40 mL/hr 4 Urine specific gravity, 1.042
3. Urine output, 40 mL/hr Rationale: Fluid resuscitation is provided at the rate needed to maintain urine output at 30-50 mL or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.
real Good The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first? 1 Administer a diuretic. 2 Provide a fluid bolus. 3 Recalculate fluid replacement based on time of hospital arrival. 4 Titrate fluid replacement.
4. Titrate fluid replacement. Rationale: The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Diuretics do not increase cardiac output, but actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.
The nurse is caring for a client who has a severe burn injury and is receiving fluid resuscitation. The nurse should assess which laboratory findings to determine the client's response to the therapy? Select all that apply. A Liver enzyme levels B Red blood cell count C White blood cell count D Serum creatinine levels E Blood urea nitrogen levels
D.Serum creatinine levels E. Blood urea nitrogen levels Rationale: Fluid shifts and fluid loss occur in clients with severe burns. Fluid resuscitation is implemented to maintain fluid balance in the client's body. Serum creatinine levels are measured to assess fluid balance in the body, whereas blood urea nitrogen levels give information about kidney function. Fluid resuscitation will not affect the liver enzyme levels, red blood cell count, or white blood cell count. Therefore, it is not necessary to monitor these laboratory values while evaluating the effects of fluid resuscitation.
