Ch. 62: Mgmt of Pts w/ Burn Injury

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 victims suffering from thermal burns?" "How many victims are anticipated for transport?" "Are the burns associated with chemicals used in the plant?" "Are any of the victims expected to have electrical burns?"

Correct response: "Are the burns associated with chemicals used in the plant?" Explanation: 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.

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? "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." "I will drink a lot of fluids to prevent constipation since I am taking pain medications." "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." "I can work with the social worker to find funding assistance programs to help with my medical expenses."

Correct response: "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." Explanation: 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.

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 stain my skin permanently." "This medication will help my burn heal."

Correct response: "This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." Explanation: 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.

When using the Palmer method to estimate the extent of a small or scattered burn injury, the nurse recognizes the palm is equal to which percentage of total body surface area? 1 2 3 4

Correct response: 1 Explanation: In clients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the clients's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

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? 9% 18% 27% 36%

Correct response: 27% Explanation: 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.

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? 9% 18% 27% 36%

Correct response: 36% Explanation: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities thathave sustained burns to entire surfaces will equal to 36% of total surface area.

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? 18% 27% 30% 36%

Correct response: 36% Explanation: 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.

A patient is admitted to a burn treatment center at 2:30 p.m. with full-thickness burns over 40% of his body. The injury occurred at 1:30 p.m. at a paper-making plant. The nurse knows that burn shock has to be prevented or treated. Based on fluid volume shifts, the nurse knows that fluid loss would peak by __________ to __________ hours, with the greatest volume being lost from __________ to__________ hours after the burn. 7:30 p.m. to 9:30 p.m.; 24 to 36 hours 4:30 p.m. to 6:30 p.m.; 6 to 8 hours 5:30 p.m. to 6:30 p.m.; 9 to 12 hours 10:30 p.m. to 12:30 a.m.; 40 to 50 hours

Correct response: 7:30 p.m. to 9:30 p.m.; 24 to 36 hours Explanation: The greatest volume of fluid loss occurs in the first 24 to 36 hours after the burn, peaking by 6 to 8 hours.

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 10 mL/hr A urinary output of 30 mL/hr A urinary output of 80 mL/hr A urinary output of 100 mL/hr

Correct response: A urinary output of 30 mL/hr Explanation: 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).

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 weight gain of 4 lb (2 kg) in 24 hours Body temperature readings all within normal limits An electrocardiogram (ECG) showing no arrhythmias

Correct response: A urine output consistently above 40 ml/hour Explanation: In a client with burns, the goal of fluid resuscitation is to maintain a mean arterial blood pressure that provides adequate perfusion of vital structures. If the kidneys are adequately perfused, they will produce an acceptable urine output of at least 0.5 ml/kg/hour. Thus, the expected urine output of a 155-lb client is 35 ml/hour, and a urine output consistently above 40 ml/hour is adequate. Weight gain from fluid resuscitation isn't a goal. In fact, a 4-lb weight gain in 24 hours suggests third spacing. Body temperature readings and ECG interpretations may demonstrate secondary benefits of fluid resuscitation but aren't primary indicators.

Which of the following measures can be used to cool a burn? Application of cool water Application of ice directly to burn Wrapping the person in ice Using cold soaks or dressings for at least 1 hour

Correct response: Application of cool water Explanation: 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.

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? Removal of clothing Irrigation of the wound Application of ice Removal of hair

Correct response: Application of ice Explanation: Application of ice causes vasoconstriction and diminishes needed blood flow to the zone of injury. Clothing and hair are removed from perimeter of burned area in an effort to remove course of bacterial contamination. Irrigation of the wound assists in the removal of debris.

A client is brought to the emergency department by a coworker following a burn injury from a high-voltage electrical power line. The triage nurse determines which intervention should be completed first? Take the client's vital signs Apply a cervical collar on the client Insert a urinary Foley catheter Obtain a 12-lead ECG

Correct response: Apply a cervical collar on the client Explanation: Until it is known that the client has no fractures, it is imperative that a neck collar be applied and remain in place and that the client is log rolled to eliminate the chance of further spinal cord injury. With high-voltage electrical injuries, cervical spine immobilization is a priority until cervical spine injury is ruled out. The other interventions may be completed; however, the priority intervention is to apply the collar.

In a client with burns on the legs, which nursing intervention helps prevent contractures? Applying knee splints Elevating the foot of the bed Hyperextending the client's palms Performing shoulder range-of-motion exercises

Correct response: Applying knee splints Explanation: Applying knee splints prevents leg contractures by holding the joints in a position of function. Elevating the foot of the bed can't prevent contractures because this action doesn't hold the joints in a position of function. Hyperextending a body part for an extended time is inappropriate because it can cause contractures. Performing shoulder range-of-motion exercises can prevent contractures in the shoulders, but not in the legs.

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 K+: 5.0 mEq/L Na+: 145 mEq/L Ca: 9 mg/dL

Correct response: BUN: 28 mg/dL Explanation: 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 skin substitutes is a nylon-silicone membrane coated with a protein? Mederma Integra Transcyte Biobrane

Correct response: Biobrane Explanation: Biobrane is a nylon-silicone membrane coated with a protein. Mederma ia a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer , and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. Transcyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.

Burn shock is characterized by which of the following? Capillary leak Severe hypervolemia Organ hyperperfusion Elevated blood pressure (BP)

Correct response: Capillary leak Explanation: Burn shock is characterized by capillary leak, "third spacing" of fluid, severe hypovolemia, and decreased cardiac output (CO). Progressive edema develops in unburned tissue and organs, causing hypoperfusion and hypovolemic shock. As fluid loss continues and vascular volume decreases, the CO and BP falls. This is the onset of burn shock.

Which complication is common for victims of electrical burns? Inhalation injury Infection Cardiac dysrhythmia Hypovolemic shock

Correct response: Cardiac dysrhythmia Explanation: 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.

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? Elevate the leg on pillows and reassess the leg in 1 hour. Document the findings and instruct the client to report numbness of the extremity. Contact the primary care provider and prepare for an escharotomy. Apply an elastic stocking to the extremity and administer SQ heparin per order.

Correct response: Contact the primary care provider and prepare for an escharotomy. Explanation: 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

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? Superficial partial thickness Deep partial-thickness Full-thickness Fourth degree

Correct response: Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis as well as injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles.

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: Epidermal layer only. Epidermis and a portion of deeper dermis. Entire dermis and subcutaneous tissue. Dermis and connective tissue.

Correct response: Epidermis and a portion of deeper dermis. Explanation: 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.

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. Insert an indwelling catheter. Replace fluids. Administer pain medication.

Correct response: Establish a patent airway. Explanation: 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.

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? Prevent infection Fluid resuscitation Endotracheal tube placement Strict intake and output

Correct response: Fluid resuscitation Explanation: 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.

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 Superficial Superficial partial-thickness Deep partial-thickness

Correct response: Full-thickness Explanation: 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.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? Anemia Gastric ulcers Hyperthyroidism Cardiac arrest

Correct response: Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? Complaints of intense thirst Moderate to severe pain Urine output of 70 ml the first hour Hoarseness of the voice

Correct response: Hoarseness of the voice Explanation: 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.

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? Autografts Heterografts Homografts Xenografts

Correct response: Homografts Explanation: Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). An autograft uses the client's own skin, which is transplanted from one part of the body to another.

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? Hypernatremia Hypokalemia Hyperkalemia Hypercalcemia

Correct response: Hyperkalemia Explanation: Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hypokalemia (potassium depletion) may occur later with fluid shifts and inadequate potassium replacement. During burn shock, serum sodium levels vary in response to fluid resuscitation. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. Hyponatremia may also occur during the first week of the acute phase, as water shifts from the interstitial space and returns to the vascular space.

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction, which is: Hyperkalemia. Hypernatremia. Hypocalcemia. Hypoglycemia.

Correct response: Hyperkalemia. Explanation: 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.

Which of the following is to be expected soon after a major burn? Select all that apply. Hypotension Tachycardia Anxiety Hypertension Bradycardia

Correct response: Hypotension Tachycardia Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn.

Following a serious thermal burn, which complication will the nurse take action to prevent first? Tissue hypoxia Infection Renal failure Hypovolemia

Correct response: Hypovolemia Explanation: After a burn, fluid from the body moves toward the burned area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

What is the key sign of onset of acute respiratory distress syndrome? Tachypnea Stridor Hypoxemia Chest pain

Correct response: Hypoxemia Explanation: The key sign of the onset of acute respiratory distress syndrome (ARDS) is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status.

Which zone of burn injury sustains the most damage? Outer Middle Inner Protective

Correct response: Inner Explanation: 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.

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? Do nothing until the chemical agent is identified. Irrigate the wounds with water. Wash the wounds with soap and water and apply a barrier cream. Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

Correct response: Irrigate the wounds with water. Explanation: The nurse should begin treatment by irrigating the wounds with water. Delaying treatment until the agent is identified allows the agent to cause further tissue damage. Washing the wounds with soap and water might cause a chemical reaction that may further damage tissue. The client may require I.V. fluid; however, the wounds should be irrigated first.

Which of the following is the effect of protein catabolism in a client with severe burns? It compromises wound healing and immunocompetence. It compromises dexterity and mobility. It maximizes the risk of sodium retention and hypotension. It maximizes the risk of impaired ventilation.

Correct response: It compromises wound healing and immunocompetence. Explanation: 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.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? Mechanical Natural Enzymatic Surgical

Correct response: Natural Explanation: Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.

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? Face only Face, neck, and chest Face and neck Neck and chest

Correct response: Neck and chest Explanation: 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.

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? Age Weight Preexisting conditions Family history

Correct response: Preexisting conditions Explanation: Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

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 Fracture of the fibula with displacement Elevation ofblood pressure and heart rate Partial-thickness burns to hands and wrists

Correct response: Presence of soot around nasal passages Explanation: 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.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition

Correct response: Pulmonary system Explanation: 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.

Which of the following is a true statement regarding the purposes of skin grafts? Increases evaporative fluid loss. Increases potential for infection. Reduces scarring and contractures. Prolongs recovery

Correct response: Reduces scarring and contractures. Explanation: Purposes of a skin graft include the reduction of scarring and contractures, to decrease evaporative fluid loss, decrease the potential for infection, and speed recovery.

A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to: Measure hourly urinary output. Replace lost fluids and electrolytes. Prevent renal shutdown. Monitor cardiac status.

Correct response: Replace lost fluids and electrolytes. Explanation: 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.

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 Acute Pain Risk for Infection Alteration in Tissue Perfusion

Correct response: Risk for Impaired Gas Exchange Explanation: 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.

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 Cover the client with a wet cloth Place the client with the head positioned slightly below the rest of the body Avoid immediate IV fluid therapy

Correct response: Roll the client in a blanket Explanation: 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.

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. Cover the client with a wet cloth. Place the client with the head positioned slightly below the rest of the body. Avoid immediate IV fluid therapy.

Correct response: Roll the client in a blanket. Explanation: 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.

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? The wound will take up to 3 weeks to heal. Pain management will be a challenge. Skin grafting will be necessary. Ligaments, tendons, muscles, and bone are not involved.

Correct response: Skin grafting will be necessary. Explanation: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.

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 Full-thickness Superficial partial-thickness Deep partial-thickness

Correct response: Superficial Explanation: 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.

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 is in hypovolemic shock. The client has experienced extensive full-thickness burns. The paramedic administered high doses of opioids during transport. The client has experienced partial-thickness burns.

Correct response: The client has experienced extensive full-thickness burns. Explanation: 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.

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 heart rate is rapid. The client's urinary output is 0.5 mL/kg/hour. The client's breathing is unlabored and skin is clammy. The client is conscious.

Correct response: The client's urinary output is 0.5 mL/kg/hour. Explanation: 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.

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? It helps determine the percentage of the total body surface area (TBSA) that is burned. The client's condition is likely to deteriorate after 72 hours. The wound is susceptible to infections. The early appearance of the burn injury may change.

Correct response: The early appearance of the burn injury may change. Explanation: 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.

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? Rule of nines Use client's palm size Parkland formula Lund and Browder burns assessment

Correct response: Use client's palm size Explanation: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

The most important intervention in the nutritional support of a client with a burn injury is to provide adequate nutrition and calories to increase metabolic rate. increase glucose demands. increase skeletal muscle breakdown. decrease catabolism.

Correct response: decrease catabolism. Explanation: 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.

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 increased metabolic rate. increased glucose demands. increased skeletal muscle breakdown. decreased catabolism.

Correct response: decreased catabolism. Explanation: 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.

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 debridement allograft silvadene application

Correct response: escharotomy Explanation: Debridement is the removal of necrotic tissue. An escharotomy is an incision into the eschar to relieve pressure on the affected area. An allograft would not be the treatment. Silvadene may be part of the treatment regimen but not specifically for this situation.

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 leathery. What depth of burn injury does the client have? full thickness (third degree) superficial (first degree) superficial partial-thickness or deep partial-thickness (second degree) fourth degree

Correct response: full thickness (third degree) Explanation: Full-thickness (third degree) burn destroys all layers of the skin and consequently is painless. The tissue appearance varies and can be dry, pale white, red, brown, leathery, charred or lifeless. Superficial (first degree) burn is similar to a sunburn. The epidermis is injured, but the dermis is unaffected. Superficial partial-thickness burn heals within 14 days, with possibly some pigmentary changes but no scarring. The deep partial-thickness (second degree) burn takes more than 3 weeks to heal, may need debridement, and is subject to hypertrophic scarring. A fourth-degree burn can involve ligaments, tendons, muscles, nerves, and bone.

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? inflammatory neuroendocrine intravascular fluid excess hypertension

Correct response: inflammatory Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

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: fluid resuscitation. infection. body image. pain management.

Correct response: pain management. Explanation: 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.

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: stasis. coagulation. hyperemia. hypotension.

Correct response: stasis. Explanation: 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.

Which antimicrobials is not commonly used to treat burns? tetracycline silver sulfadiazine (Silvadene) mafenide (Sulfamylon) silver nitrate (AgNO3) 0.5% solution

Correct response: tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns.

A nurse is caring for a client with skin grafts covering full-thickness burns on the arms and legs. During dressing changes, the nurse should: apply maximum bandages to allow for absorption of drainage. wrap elastic bandages distally to proximally on dependent areas. wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. remove bandages with clean gloves.

Correct response: wrap elastic bandages distally to proximally on dependent areas. Explanation: Wrapping elastic bandages on dependent areas limits edema formation and bleeding and promotes graft acceptance. The nurse should wrap the client's arms and legs from the distal to proximal ends and use strict sterile technique throughout the dressing change. The nurse shouldn't use maximum bandages because bulky dressings limit mobility; instead, the nurse should use enough bandages to absorb wound drainage. Sterile gloves are required throughout all phases of the dressing change to prevent contamination.