Ch 62 Burns Critical Care
Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?
Sulfadiazine, silver (Silvadene)
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?
Mechanical debridement
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)
The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies
Hyperkalemia
A young child is being evaluated for area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the useof which assessment tool?
Lund and Browder method
In a client who has been burned, which medication should the nurse expect to use to prevent infection?
Mafenide (Sulfamylon)
A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat?
Moisten with sterile water only. Expl: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
Paralytic ileus
When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?
1
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36%
A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation?
"An allograft is a temporary wound covering obtained from cadaver skin."
A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?
"Are the burns associated with chemicals used in the plant?" Expl: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel. 1853
The nurse has completed teaching home care instructions to a patent being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Expl: Itching is a normal part of healing. Many clients describe this as one of the most uncomfortable aspects of burn recovery. The client can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The client should pat the areas; scratching is contraindicated. The other statements indicate that teaching has been effective. 1866
When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?
.5
When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area?
1%
The palm represents which percentage of a person's TBSA?
1% pg. 1809
A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2,400 mL
A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2,400 mL pg. 1815
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27% Expl: According to the Rule of Nines, the posterior trunk, anterior trunk, and legs each make up 18% of the total body surface. The head, neck, and arms each make up 9% of total body surface, and the perineum makes up 1%. In this case, the client received burns to his back (18%) and one arm (9%), totaling 27% of his body. 1848
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27% Expl: The TBSA would be 27%. 18% for the anterior trunk and 9% for the left arm. 1848
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36% Expl: The Rule of Nines divides body surface area into percentages that, when totaled, equal 100%. According to the Rule of Nines, the arms account for 9% each, the anterior legs account for 9% each, and the anterior trunk accounts for 18%. Therefore, this client's burns cover 36% of the body surface area. 1848
A 42-year-old client suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. Which of the following conditions create the need for intensive care by specifically trained personnel?
All options are correct
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?
5 days
As the first priority of care, a patient with a burn injury will initially need:
A patent airway established. Expl: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. 1853
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
A urinary output of 30 mL/hr Expl: For adults, a urine output of 30 to 50 mL per hour is used as an indication of appropriate resuscitation in thermal and chemical injuries, whereas in electrical injuries a urine output of 75 to 100 mL per hour is the goal (ABA, 2011a). 1857
In an industrial accident, a client who weighs 155 lb (70 kg) sustained full-thickness burns over 40% of his body. He's in the burn unit receiving fluid resuscitation. Which finding shows that the fluid resuscitation is benefiting the client?
A urine output consistently above 40 ml/hour
A nurse is caring for a patient who has sustained a deep partial-thickness burn injury. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to what nursing diagnosis?
Acute Pain
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client.
Allograft Expl: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft. 1864
Which of the following measures can be used to cool a burn?
Application of cool water Expl: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. Pg. 1854
Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?
Application of ice
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?
As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery. Expl: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively. 1964
When caring for a client with burns, how often should a nurse change the wound dressing? Choose the correct option.
At least once a day
Which type of graft utilizes the client's own skin for wound coverage?
Autograft
A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?
BUN: 28 mg/dL
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL Expl; The elevated BUN would cause the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits.
Which of the following is a disadvantage of surgical debridement?
Bleeding Expl: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement. 1862
The nurse cares for a client with extensive burn injuries. Which parameter(s) would the nurse evaluate to determine if the client is receiving adequate fluid resuscitation? Select all that apply.
Blood pressure, Heart rate, Urine output Expl: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits
Which complication is common for victims of electrical burns?
Cardiac Dysrhythmia Expl: Cardiac dysrhythmias are common for victims of electrical burns. If the patient has an electrical burn, a baseline electrocardiogram (ECG) is obtained and continuous monitoring is initiated. Any burn injury can lead to complications, such as inhalation injury, infection, and hypovolemic shock.
Which of the following complications is common for victims of electrical burns?
Cardiac dysrhythmia
Which zone consists of the area where the injury is most severe and deepest?
Coagulation Expl: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis. 1849
Which of the following is a quick assessment technique to assess the percentage of burn injury? Choose the correct option.
Comparing the client's palm with the size of the burn wound
Which is a quick technique to assess the percentage of a burn injury?
Comparing the client's palm with the size of the burn wound Expl: A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.
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. Expl: The nurse assesses peripheral pulses frequently with a Doppler ultrasound device, if needed. Frequent assessment also includes warmth, capillary refill, sensation, and movement of extremity. It is necessary for the nurse to report loss of pulse or sensation or presence of pain to the physician immediately and to prepare to assist with an escharotomy. The other interventions are inappropriate when the nurse has detected a loss of peripheral pulses. 1851
Which of the following provides clues about fluid volume status? Select all that apply.
Daily weights, Hourly urine output. Expl: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient. 1866
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following?
Decreased catabolism
A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?
Decreased peristalsis
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis?
Deep partial-thickness
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?
Deep partial-thickness
Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?
Deep tissue cooling
A nurse helps a health care provider treat a full-thickness burn on a patient's hand. Prior to treatment, the nurse documents the appearance of the wound as:
Dry and pale white.
A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?
Early appearance of the burn injury may change. Expl: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours. 1849
A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort?
Education about home safety
The spouse of a victim, who was struck by lightning, asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?
Electrical burns usually follow an internal path.
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?
Electrical burns usually follow an internal path. Expl: Electrical current follows the path of less resistance. Becausethe skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current. 1850
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
Epidermis and a portion of deeper dermis. Expl: A deep partial-thickness burn includes the epidermis, upper dermis, and a portion of the deeper dermis. A burn limited to the epidermal layer is classified as a superficial partial-thickness burn. The last two choices refer to a full-thickness burn. Pg. 1847
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?
Escharotomy
The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?
Establish a patent airway. Expl: Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration to stabilization of airway, breathing, and circulation. 1853
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?
Fluid resuscitation Expl: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystalloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts. 1854
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have?
Full thickness (third degree)
Which type of burn injury requires skin grafting?
Full-thickness
A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?
Full-thickness Expl: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. 1848
Skin grafts are necessary for which of the following burns?
Fullthickness
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
Gastric ulcers
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?
Have someone assist him into a bath of cool water, where he can wait for emergency personnel. Expl: After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process. 1854
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice Expl: Hoarseness is indicative of injury to the respiratory system and could indicate the need for immediate intubation. Thirst following burns is expected because of the massive fluid shifts and resultant loss, leading to dehydration. Pain, either severe or moderate, is expected with a burn injury. The client's urine output is adequate. 1857
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?
Hyperglycemia Expl: When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially. 1860
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction which is:
Hyperkalemia. Expl: Circulating blood volume decreases dramatically during burn shock due to severe capillary leak with variation of serum sodium levels in response to fluid resuscitation. Usually, hyponatremia (sodium depletion) is present. Immediately after burn injury, hyperkalemia (excessive potassium) results from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. 1851
Which of the following is to be expected soon after a major burn? Select all that apply. Bradycardia Hypertension Tachycardia Hypotension Anxiety
Hypotension Tachycardia Anxiety
Following a serious thermal burn, which complication will the nurse take action to prevent first?
Hypovolemia
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?
Identification by the destruction of the dermis and epidermis Expl: Third-degree (full-thickness) burns involve total destruction of the epidermis and dermis and, in some cases, destruction of underlying tissue. Second-degree burns are associated with blister formation. 1847
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water. Expl: The application of cool water is the best first-aid measure. Soaking the burned area intermittently in cool water or applying cool towels gives immediate and striking relief from pain and limits local tissue edema and damage. 1847
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
Impaired risk for gas exchange
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 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?
Inflammatory
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
Intravenous Expl: Intravenous administration is necessary because of altered tissue perfusion from burn injury. Pg. 1858
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
A patient is admitted to the burn unit after being transported from a facility 1000 miles away. The patient has burns to the groin area and circumferential burns to both upper thighs. When assessing the patient's legs distal to the wound site, the nurse should be cognizant of the risk of what complication?
Ischemia
Which of the following is the effect of protein catabolism in a client with severe burns?
It compromises wound healing and immunocompetence. Expl: Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention. 1865
A patient's burns are estimated at 36% of total body surface area; fluid resuscitation has been ordered in the emergency department. After establishing intravenous access, the nurse should anticipate the administration of what fluid?
Lactated Ringer's
Which of the following is the preferred IV fluid for burn resuscitation?
Lactated Ringer's (LR) Expl: LR is the preferred IV fluid for burn resuscitation because the sodium concentration and potassium are similar to normal intravascular levels. NS, D5W, and TPN are not the IV of choice for burn resuscitation Pg. 1854
The nurse is caring for a patient with deep partial-thickness burn injuries. Which of the following statements reflect current research regarding the utilization of nonpharmacological measures in the management of burn pain?
Music therapy may provide reality orientation, distraction, and sensory stimulation.
Which of the following statements reflect current research regarding the utilization of nonpharmacological measures in the management of burn pain?
Music therapy may provide reality orientation, distraction, and sensory stimulation.
The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?
Music therapy may provide reality orientation, distraction, and sensory stimulation. pg. 1826
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
Myoglobin in the urine Expl: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema. 1856
The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury?
Narrowing pulse pressure
Which type of debridement occurs when nonliving tissues sloughs away from uninjured tissues?
Natural
A client with superficial burns on the face and deep partial-thickness burns on the neck and chest is undergoing treatment and is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested?
Neck and chest Expl: Skin grafting is essential for deep partial-thickness burns on the client's neck and chest because the skin layers responsible for regeneration have been destroyed. The client's face does not need skin grafting because the burns are superficial and will heal unassisted.1863
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.
Place the client in a horizontal position, Roll the client in a blanket to smother the fire. Expl: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire. 1854
The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn?
Preexisting conditions
A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include
Premedicating the patient with an analgesic prior to application Expl: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide. Mafenide Acetate 5%=(Sulfamylon). 1862
After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?
Presence of soot around nasal passages Expl: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed. 1867
Which instruction is the most important to give a client who has recently had a skin graft?
Protect the graft from direct sunlight.
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system Expl: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs. 1853
Which of the following is a true statement regarding the purposes of skin grafts?
Reduces scarring and contractures.
Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase?
Reduction in blood volume pg. 1813
A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase?
Related to circumferential eschar
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
Replace lost fluids and electrolytes. Expl: After managing respiratory difficulties, the next most urgent need is to prevent irreversible shock by replacing lost fluids and electrolytes. The total volume and rate of IV fluid replacement are gauged by the patient's response and guided by the resuscitation formula. 1851
A client, who has sustained burns to the anterior chest and upper extremities, is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
Risk for Impaired Gas Exchange Expl: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues. 1853
Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire?
Roll the Client in a blanket Expl: At the scene of a fire, the client should be rolled in a blanket to smother the fire. The client should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital. 1854
The nurse participates in a health fair about fire safety. When clothes catch fire, which intervention helps to minimize the risk of further injury to an affected person at a scene of a fire?
Roll the client in a blanket Expl: When clothing catches fire, the flames can be extinguished if the person drops to the floor or ground and rolls ("stop, drop, and roll"); anything available to smother the flames, such as a blanket, rug, or coat, may be used. The older adult, or others with impaired mobility, could be instructed to "stop, sit, and pat" to prevent concomitant musculoskeletal injuries. The client should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital. 1854
The nurse is participating in a health fair about fire safety. Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire when clothes catch fire?
Roll the patient in a blanket.
A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following?
Severe burning pain for up to 20 minutes
The nurse knows that which topical antibacterial agent does not penetrate eschar?
Silver nitrate 0.5% Expl: Does not Penetrate Eschar 1862
The client is admitted with full-thickness burn to the forearm. Which is the most accurate interpretation made by the nurse?
Skin grafting will be necessary.
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
Skin grafting will be necessary. pg. 1807
A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?
Superficial Expl: A superficial burn only damages the epidermis. A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. 1847
Which type of burn is similar to a sunburn?
Superficial partial-thickness
An emergency department nurse learns from the paramedics that they are transporting a patient who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn?
The causative agent
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
The client has experienced extensive full-thickness burns. Expl: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement. 1847
A nurse is preparing a care plan for a client burned over 36% of his body 2 days previously. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care?
The client's complete blood count readings reflect a reduced hematocrit.
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?
The client's urinary output is 0.3 to 0.5 mL/kg/hour. Expl: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status. 1854
Which of the following is true regarding a split-thickness skin graft?
The epidermis and a thin layer of dermis are harvested from the client's skin.
An emergency department nurse has just admitted a patient with a burn. What characteristic of the burn will primarily determine whether the patient experiences a systemic response to this injury?
The total body surface area (TBSA) affected by the burn
Which is the primary reason for placing a client in a horizontal position while smothering flames are present?
To keep fire and smoke from airway
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
To prevent contractures
A nurse is assessing a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which finding indicates a potential problem?
Urine output of 20 ml/hour Expl: A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.1854
When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?
Use client's palm size
What is an early sign of sepsis in the burn injured client?
Widened pulse pressure
Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?
Zone of stasis
Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The area of intermediate burn injury is the zone in which blood vessels are damaged, but tissue has the potential to survive. This is called the zone of:
Zone of stasis Expl: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. The zone of hypotension is not the name of one of the zones. 1849
The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply.
• The perineum • The face
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to
decrease catabolism. Expl: The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. 1865
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to
decrease catabolism. pg. 1806
The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories. The nurse recognizes this intervention is to promote
decreased catabolism. Expl: Burn injuries produce profound metabolic abnormalities fueled by the exaggerated stress response to the injury. The body's response has been classified as hyperdynamic, hypermetabolic, and hypercatabolic. The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to decrease catabolism. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. 1865
A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:
dislodge the autografts.
A client has a third-degree burn on the leg. The wound is being treated by the open method. After about 4 days, a hard crust has formed around the leg and is impairing the circulation to the leg. What procedure would be done to relieve pressure on the affected area?
escharotomy Expl: 1851
Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
Specific potential complications are common to specific types of burns. Which burns can impair ventilation? perineal face, neck, chest hands, major joints All options are correct.
face, neck, chest Expl: Burns of the face, neck, or chest have the potential to impair ventilation.
A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared charred. What depth of burn injury does the client have?
full thickness (third degree)
A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure?
hemoconcentration
The nurse is caring for a patient who has sustained severe burns to 50% of the body. The nurse is aware that fluid shifts during the first week of the acute phase of a burn injury cause massive cell destruction. What should the nurse report immediately when reviewing laboratory studies?
hyperkalemia
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory Expl: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury. 1850
Which zone of burn injury sustains the most damage?
inner Expl:: Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, includes a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage. 1849
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
pain management Expl: With a superficial partial-thickness burn such as a solar burn, the nurse's main concern is pain management. Fluid resuscitation and infection become concerns if the burn extends to the dermal and subcutaneous skin layers. Body image disturbance is a concern that has lower priority than pain management. 1847
Which antimicrobials is not commonly used to treat burns?
tetracycline Expl: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns. 1862
A client is cared for in a burn unit after suffering partial-thickness burns. The client's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine to be applied to the client's burns. The nurse provides information to the client about the medication. Which statement made by the client indicates an understanding about this treatment? Select all that apply.
• "This medication is an antibacterial." • "This medication will be applied directly to the wound." • "This medication will help my burn heal." Expl: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the client's skin, but it will help heal the client's burned areas. 1862
Which of the following is to be expected soon after a major burn? Select all that apply.
• Anxiety • Tachycardia • Hypotension
The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? (Select all that apply.)
• Base-bicarbonate deficit • Elevated hematocrit level • Sodium deficit