Burns

The nurse is caring for a 22-year-old client with a circumferential burn to the left thigh. What assessment should the nurse perform as a priority specific to this type of burn?

Color, warmth, circulation, sensation, and movement of the left lower leg and foot

Skin grafts are necessary for what type of burn?

Full-thickness

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?

Lund and Browder method

A 2-year-old client presents to the emergency department after a burn with scalding hot tea (above). What treatment does the nurse anticipate for this child?

application of a silver and silicone dressing

During the acute phase of a burn, a nurse should assess:

circulatory status.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:

maintaining the client's fluid, electrolyte, and acid-base balance.

The nurse cares for a client with superficial partial-thickness burn injuries to the lower extremities. The client is ordered IV morphine for pain. The nurse understands narcotics are given via IV during the initial management of pain because

tissue edema may interfere with drug absorption via other routes.

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?

27%

The nurse provides care for a client with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the client is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. What is the nurse's best response based on the clinical findings?

Contact the primary care provider and prepare for an escharotomy.

Which of the following types of shock will a nurse observe in a client with extensive burns?

Hypovolemic shock

A client experienced a 33% TBSA burn 72 hours ago. The nurse observes that the client's hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?

Recognize that the client is experiencing an expected onset of diuresis.

A nurse is caring for a client in the emergent/resuscitative phase of burn injury. During this phase, the nurse should monitor for evidence of what alteration in laboratory values?

Sodium deficit

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?

Sulfadiazine, silver (Silvadene)

Which type of burn is similar to a sunburn?

Superficial partial-thickness

An emergency department nurse is caring for a 5-year-old child who was just brought in by ambulance with partial-thickness (second-degree) and full-thickness (third-degree) burns to their face, neck, and chest. The client is awake and alert. Vital signs: temperature, 97.2°F (36.2°C); heart rate, 148 beats/min; blood pressure, 68/39 mm Hg; respiratory rate, 32 breaths/min; oxygen saturation, 90% on 2 liters by nasal cannula.

-Apply oxygen to maintain oxygen saturations 95% or greater. -Administer 100 mcg/kg morphine via intravenous push (IVP) for pain prn q4 hour. -Initiate fluid resuscitation per Lund and Browder chart using Parkland formula with 0.9% saline.

A client presents to the emergency department following a burn injury. The client has burns to the abdomen and front of the left leg. Using the rule of nines, the nurse documents the total body surface area percentage as

18%.

Which of the following is a common complication of an electrical burn injury?

Cardiac dysrhythmias

Specific potential complications are common to specific types of burns. Which burns can impair ventilation?

face, neck, chest

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?

Airway management