Burns Practice Questions
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
1 After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes. 2. This is important, but it is not priority over fluid volume balance, and this is not a collaborative intervention because the nurse can do this independently. 3. Output must be monitored, but this is an independent intervention. 4. An escharotomy, an incision that releases scar tissue that prevents the body from being able to expand, enables chest excursion in circumferential chest burns. The client has not had time to develop eschar. TEST-TAKING HINT: A collaborative intervention is an intervention that requires an HCP's order or working with another discipline. Therefore, options "2" and "3" should be eliminated immediately.
There has been a fire in an apartment building. All residents have been evacuated , but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply. 1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA). 2. A 20 -year-old who inhaled the smoke of the fire. 3. A 50-year-old diabetic with first- andsecond-degree burns on his left forearm (about 5% of his BSA). 4. A 30-year-old with second-degree burns on the back of his left leg. 5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA).
1, 2, 3. Clients who should be transferred to a burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their BSA, clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA , clients of any age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.
1,2,3,5 1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn. 2. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 3. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. 5. Antibiotics reduce bacteria. 4. Invasive lines and tubing should be changed daily. TEST-TAKING HINT: Alternative-type questions require the test taker to choose all options that apply. Infection is a priority for clients with burns.
Which of the following clients with burns will most likely require an endotracheal or tracheostomy tube? A client who has: 1. Electrical burns of the hands and arms causing arrhythmias. 2. Thermal burns to the head, face, and airway resulting in hypoxia 3. Chemical burns on the chest and abdomen. 4. Secondhand smoke inhalation.
2 Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who have experienced burns to the face and neck usually will be compromised within 1 to 2 hours. Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation does influence an individual's respiratory status but does not require intubation unless the individual has an allergic reaction to the smoke.
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain? 1. Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol). 2. Intravenous opioids. 3. Intramuscular opioids. 4. Oral antianxiety agents such as lorazepam (Ativan).
2 The severe pain experienced by burn clients requires opioid analgesics. In addition, opioids such as morphine sedate and alleviate apprehension. Oral analgesics such as ibuprofen or acetaminophen are unlikely to be strong enough to effectively manage the intense pain experienced by the client who is severely burned. Because of the altered tissue perfusion from the burn injury, intravenous medications are preferred . Antianxiety agents are not effective against pain.
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
3 A xenograft or heterograft consists of skin taken from animals, usually porcine. 1. This is the explanation for an autograft. 2. This is the description of a homograft. 4. This is "passing the buck"; the nurse can and should answer this question with factual information. TEST-TAKING HINT: The test taker should eliminate options to help determine the correct answers. Option "1" can be eliminated because skin from self would be auto-, not xeno-. Option "4" should be eliminated because the nurse should answer the question and not pass the buck.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.
3 Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention. 1. The client should be premedicated with an analgesic because this agent causes severe burning pain for up to 20 minutes after application. 2. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. Also, these electrolytes are WNL and would not require immediate intervention. 4. The client being able to perform range-of motion exercises does not warrant immediate intervention; this is a very good result. TEST-TAKING HINT: "Require immediate attention" means that the nurse must intervene independently or notify another health-care provider. The test taker must know how to interpret ABGs, and, even if the test taker is not familiar with the medication, metabolic acidosis requires intervention.
Which of the following factors would have the least influence on the survival and effectiveness of a burn victim's porcine grafts? 1. Absence of infection in the wounds. 2. Adequate vascularization in the grafted area. 3. Immobilization of the area being grafted 4. Use of analgesics as necessary for pain relief.
4 Analgesic administration to keep a burn victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immobilization of the grafted area promote an effective graft. CN: Physiological adaptation;
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to: 1. Correct water and electrolyte imbalances. 2. Allow the gastrointestinal tract to rest. 3. Provide supplemental vitamins and minerals. 4. Ensure adequate caloric and protein
4 Nutritional support with sufficient calories and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate . Gastric dilation and paralytic ileus commonly occur in clients with severe burns, making oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of IV fluids with electrolyte additives, although TPN typically includes all necessary electrolytes. Resting thegastrointestinal tract may help prevent paralytic ileus, and TPN provides vitamins and minerals ; however, the primary reason for starting TPN is to provide the protein necessary for tissue healing.
Using the Parkland formula, calculate the hourly rate of fluid replacement with lactated Ringer's solution during the first 8 hours for a client weighing 75 kg with total body surface area (TBSA) burn of 40%. _______________ mL/ hour.
750 mL/hour. Lactated Ringer's solution 4 mL × weight in kg × TBSA; half given over the first 8 hours and half givenover the next 16 hours.
A client is admitted to the hospital after sustaining burns to the chest, abdomen , right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," estimate what percentage of the client's body surface has been burned. 1. 18%. 2. 27%. 3. 45%. 4. 64%.
3 According to the rule of nines, this client has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit.
1 Although this is a potential problem, it is priority because the body's protective barrier, the skin, has been compromised and there is an impaired immune response. 2. This psychosocial client problem is important, but in the ICU the first priority is preventing infection so wound healing can occur. 3. Burn wound edema, pain, and potential joint contractures can cause mobility deficits, but the first priority is preventing infection so wound healing can occur. 4. Teaching is always important, but in the ICU the priority is the physiological integrity of the client. TEST-TAKING HINT: The adjectives "intensive care" mean the client is critically ill; therefore, a physiological problem is priority and options "2" and "4" can be eliminated. Although actual is usually higher priority than potential, in the case of a burn the risk for infection has to be priority.
During the emergent (resuscitative)phase of burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation? 1. Serum creatinine level of 2.5 mg/ dL (221 μmol/ L). 2. Little fluctuation in daily weight. 3. Hourly urine output of 60 mL. 4. Serum albumin level of 3.8 (38 g/ L).
1 Fluid shifting into the interstitial space causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine output should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/ h. Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP readings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns, causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 g/ dL (35 to 50 g/ L).
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
1 The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client's recovery. 2. The client should be provided a highcalorie, high-protein diet along with vitamins. 3. The client should be weighed daily, and the goal is that the client loses no more than 5% of preburn weight. 4. The nurse would make a referral to a dietitian, not a social worker. TEST-TAKING HINT: The nurse needs to be knowledgeable of different types of diets; this requires memorization.
The nurse is caring for a client with severe burns who is receiving fluid resuscitation. Which of the following indicates that the client is responding to the fluid resuscitation? 1. Pulse rate of 112. 2. Blood pressure of 94/ 64. 3. Urine output of 30 mL/ h. 4. Serum sodium level of 136 mEq/ L (136 mmol/ L).
3 Ensuring a urine output of 30 to 50 mL/ h is the best measure of adequate fluid resuscitation. The heart rate is elevated, but is not an indicator of adequate fluid balance. The blood pressure is low, likely related to the hypervolemia, but urinary output is the more accurate indicator of fluid balance and kidney function. The sodium level is within normal limits.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they: 1. Encourage the formation of tough skin. 2. Promote the growth of epithelial tissue 3. Provide for permanent wound closure. 4. Facilitate the development of subcutaneous tissue.
2 Biologic dressings such as porcine grafts serve many purposes for a client with severe burns. They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
2 Cool water gives immediate and striking relief from pain and limits local tissue edema and damage. 1. Ice should never be applied to a burn because this will worsen the tissue damage by causing vasoconstriction. 3. Blisters should be maintained intact to prevent infection. 4. The client should be told to go to the ED, not the doctor's office, for burn care. TEST-TAKING HINT: The test taker should select an answer that directly cares for the client's body. This eliminates options "3" (blisters have not formed yet) and "4." Therefore, the test taker has to decide between cool water and ice.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
2 Daily cleaning reduces bacterial colonization. 1. Addressing pain will not address impaired skin integrity. 3. This intervention would be appropriate for a "risk for infection" nursing diagnosis. 4. Plants and flowers in water should be avoided because stagnant water is a source for bacterial growth. TEST-TAKING HINT: The intervention addresses the etiology of the nursing diagnosis "open burn wounds," and the goal addresses the response "impaired skin integrity."
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
2 Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema. 1. Sunburn is an example of this depth of burn; a superficial partial-thickness burn affects the epidermis and the skin is reddened and blanches with pressure. 3. Full-thickness burns are caused by flame, electric current, or chemical burns and include the epidermis, entire dermis, and sometimes subcutaneous tissue and may also involve connective tissue, muscle, and bone. 4. First-degree burn is another name for a superficial partial-thickness burn. TEST-TAKING HINT: The adjectives in the stem are the most important words that assist the test taker when selecting a correct answer.
The rate at which IV fluids are infused is based on the burn client's: 1. Lean muscle mass and body surface area (BSA) burned. 2. Total body weight and BSA burned. 3. Total BSA and BSA burned. 4. Height and weight and BSA burned.
2 During the first 24 hours, fluid replacement for an adult burn client is based on total body weight and BSA burned. Lean muscle mass considers only muscle mass; replacement is based on total body weight . Total surface area is estimated by taking into account the individual's height and weight.
The nurse should plan to begin rehabilitation efforts for the burn client: 1. Immediately after the burn has occurred. 2. After the client's circulatory status has been stabilized. 3. After grafting of the burn wounds has occurred. 4. After the client's pain has been eliminated.
2 Rehabilitation efforts are implemented as soon as the client's condition is stabilized. Early emphasis on rehabilitation is important to decrease complications and to help ensure that the client will be able to make the adjustments necessary to return to an optimal state ofhealth and independence . It is not possible to completely eliminate the client's pain; pain control is a major challenge in burn care.
Which of the following activities should the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change? 1. Soak the dressing. 2. Remove the dressing. 3. Administer an analgesic. 4. Slit the dressing with blunt scissors.
3 Removing dressings from severe burns exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.
The client is being discharged after being in the burn unit for six weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.
3 The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time. 1. The client should resume previous activities gradually and should not stay home; the client should go out and begin to live again. 2. The client should be honest with self, family, and friends about needs, hopes, and fears. 4. The client should feel free to discuss feelings with family, friends, and the therapist. TEST-TAKING HINT: Even if the test taker is not familiar with the disease process, there are certain interventions that go with any chronic problem, such as getting back to normal life as soon as possible and being independent, but also getting help when needed and not expecting too much too soon.
A client is receiving fluid replacement with lactated Ringer's after 40% of the body was burned 10 hours ago. The assessment reveals temperature 36.2 ° C, heart rate 122 , blood pressure 84/ 42, Central venous pressure (CVP) 2 mm Hg, and urine output 25 mL for the last 2 hours. The IV rate is currently at 375 mL /h. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the health care provider with a recommendation for: 1. Furosemide (Lasix). 2. Fresh frozen plasma. 3. IV rate increase. 4. Dextrose 5%.
3 The decreased urine output, low blood pressure, low CVP, and high heart rateindicate hypovolemia and the need to increase fluid volume replacement. Furosemide is a diuretic that should not be given due to the existing fluid volume deficit. Fresh frozen plasma is not indicated. It is given for clients with deficient clotting factors who are bleeding . Fluid replacement used for burns is lactated Ringer's solution, normal saline, or albumin.
After the initial phase of the burn injury, the client's plan of care will focus primarily on: 1. Helping the client maintain a positive self-concept. 2. Promoting hygiene. 3. Preventing infection. 4. Educating the client regarding care of the skin grafts.
3 The inflammatory response begins when a burn is sustained. As a result of the burn, the immune system becomes impaired. There are a decrease in immunoglobulins, changes in white blood cells, alterations of lymphocytes, and decreased levels of interleukin. The human body's protective barrier, the skin, has been damaged. As a result, the burn client becomes vulnerable to infections. Education and interventions to maintain a positive self-concept would be appropriate during the rehabilitation phase. Promoting hygiene helps the client feel comfortable; however, the primary focus is on reducing the risk for infection.
The nurse is assessing an 80-year-old client who has scald burns on the hands and both forearms (first- and second-degree burns on 10% of the body surface area). What should the nurse do first? 1. Clean the wounds with warm water. 2. Apply antibiotic cream. 3. Refer the client to a burn center. 4. Cover the burns with a sterile dressing.
3. The nurse should have the client transported to a burn center. The client's age and the extent of the burns require care by a burn team and the client meets triage criteria for referral to a burn center. Because of theage of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.
The nurse is conducting a focused assessment of the gastrointestinal system of a client with a burn injury . The nurse should assess the client for: 1. Paralytic ileus 2. Gastric distention. 3. Hiatal hernia. 4. Curling's ulcer.
4 Curling's ulcer, or gastrointestinal ulceration, occurs in about half of the clients with a burn injury. The incidence of ulceration appears proportional to the extent of the burns, and the ulceration is believed to be caused by hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus and gastric distention do not result from hypersecretion of gastric acid and stress. Hiatal hernia is not necessarily a potential complication of a burn injury.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.
4 Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention. 1. Severe pain would be expected in a client with these types of burns; therefore, it would not warrant notifying the health-care provider. 2. A pulse oximeter reading greater than 93% is WNL. Therefore, a 95% reading would not warrant notifying the health-care provider. 3. The client's vital signs show an elevated temperature, pulse, and respiration, along with a low blood pressure, but these vital signs would not be unusual for a client with severe burns. TEST-TAKING HINT: The test taker must select an answer that is not expected for the client's disease or condition when being asked which data
During the early phase of burn care, the nurse should assess the client for? 1. Hypernatremia. 2. Hyponatremia. 3. Metabolic alkalosis. 4. Hyperkalemia.
4 Immediately after a burn, excessive potassium from cell destruction is released into the extracellular fluid. Hyponatremia is a common electrolyte imbalance in the burn client that occurs within the first week after being burned. Metabolic acidosis usually occurs as a result of the loss of sodium bicarbonate.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.
4 The client's legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes. 1. An 18-gauge catheter with lactated Ringer's infusion should be initiated to maintain a urine output of at least 30 mL/hr. 2. Wounds should be covered with a clean, dry sheet. 3. The client should be transferred with adequate pain relief, which requires intravenous morphine. TEST-TAKING HINT: Note the adjectives "22-gauge" and "moist." If the test taker is unsure of the correct answer, then the test taker should determine which system is affected and see if that will help determine the right answer. A client's extremities and a neurovascular assessment are similar; therefore, the test taker should select option "4."
