CHAPTER 26: CARE OF PATIENTS WITH BURNS

10. A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority? a. Apply oxygen and continuous pulse oximetry. b. Allow the client to suck on small quantities of ice chips. c. Request an antitussive medication from the physician. d. Have the respiratory therapist provide humidified room air.

ANS: A Brassy cough and wheezing are some of the signs seen with inhalation injury. The first action by the nurse is to give the client oxygen. Clients with possible inhalation injury also need continuous pulse oximetry. Ice chips and humidified room air will not help the problem, and antitussives are not warranted.

32. The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner? a. Supine with one pillow behind the head b. Semi-Fowler's position with arms elevated c. Wrists extended to 30 degrees in a splint d. A towel roll placed under the neck or shoulder

ANS: A Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture.

26. Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a thermal burn injury? a. Allowing the client to eat whenever he or she wants b. Beginning parenteral nutrition high in calories c. Including 3000 kcal/day of calories with meals d. Providing a low-protein, high-fat diet

ANS: A Clients should request food whenever they think they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.

31. Which intervention by the nurse is most appropriate to reduce a client's pain after a burn injury? a. Administering morphine sulfate 4 mg intravenously b. Administering morphine sulfate 4 mg intramuscularly c. Applying ice to the burned area for 20 minutes d. Avoiding tactile stimulation near the burned area

ANS: A Drug therapy for pain management requires opioid and non-opioid analgesics. The IV route is used because of problems with absorption from the muscle and the stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering, the room must be kept warm, and ice should not be used. Ice would decrease blood flow to the area.

9. Which finding indicates to the nurse that a client understands the psychosocial impact of a severe burn injury? a. "It is normal to feel some depression." b. "I will go back to work immediately." c. "I will not feel anger about my situation." d. "Once I get home, things will be normal."

ANS: A During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

30. The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts? a. "Because the graft is my own skin, there is no chance it won't 'take.'" b. "For a few days after surgery, the donor sites will be painful." c. "I will have some scarring in the area where the skin is removed." d. "I am still at risk for infection after the procedure until the burn heals."

ANS: A Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Donor sites will be painful after surgery, scarring can occur in the area where skin is removed for grafting, and the client is still at risk for infection.

29. The nurse uses topical gentamicin sulfate (Garamycin) on a client's burn injury. Which laboratory value does the nurse monitor? a. Creatinine b. Red blood cells c. Sodium d. Magnesium level

ANS: A Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium level.

20. A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action does the nurse take first? a. Begin intravenous fluid resuscitation. b. Check pulses with a Doppler device. c. Obtain a complete blood count (CBC). d. Obtain an electrocardiogram (ECG).

ANS: A Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action.

18. Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What action by the nurse is most appropriate? a. Document the finding. b. Obtain a family history for diabetes. c. Repeat the glucose measurement. d. Stop IV fluids containing dextrose.

ANS: A Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. A family history of diabetes could place her at higher risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid.

6. The nurse has provided instruction on the facial pressure garment to a client with facial burns. Which statement indicates that the client understands these instructions? a. "My scars should be less severe with the use of this mask." b. "The mask will help protect my skin from sun damage." c. "This treatment will help prevent infection." d. "Using the mask will keep scars from being permanent."

ANS: A The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not alter the risk for infection.

21. A client is brought to the emergency department by an emergency medical services (EMS) squad after being burned with unknown chemicals. The client's body is covered with a white, powdery substance, and the client cries out, "Get this stuff off me! It's burning me!" Which action by the nurse is most appropriate? a. Have the client take a shower, and bag all clothing. b. Brush the substance off the client and remove clothes. c. Call poison control to try to identify the chemical. d. Start an IV line and prepare to administer analgesics.

ANS: B A priority first action in burn care is to stop the burning process. Chemicals can continue to burn the client even after they have been removed, so removing them from the client is an important action. With unknown dry substances, adding water could potentiate their action, so the best action is to brush off as much of the chemical as possible from the client and clothing, then remove the clothing. Calling poison control would take too long if the chemical could be identified, and analgesics should be given after the burning process has been halted by removal of the offending substance.

2. When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by autocontamination? a. Avoid sharing equipment such as blood pressure cuffs between clients. b. Change gloves between wound care on different parts of the client's body. c. Use the closed method of burn wound management for all wound care. d. Use proper and consistent handwashing by all members of the staff.

ANS: B Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on different parts of the client's body can prevent autocontamination.

4. The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? a. Have an escape route everyone knows about. b. Keep a smoke detector in each bedroom. c. Use space heaters instead of gas heaters. d. Use carbon monoxide detectors in the garage.

ANS: B Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom should have a separate smoke detector. Smoke detectors should also be placed in the hallway of each story, in the kitchen, in each stairwell, and by each entrance. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. An escape route is very important, but successfully escaping also depends on early recognition of a fire, which is assisted by smoke detectors.

33. A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge

ANS: B Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.

16. A client who is receiving fluid resuscitation per the Parkland formula after a serious burn continues to have urine output ranging from 0.2 to 0.25 mL/kg/hour. After the health care provider checks the client, which order does the nurse question? a. Increase IV fluids by 100 mL/hr. b. Administer furosemide (Lasix) 40 mg IV push. c. Continue to monitor urine output hourly. d. Draw blood for serum electrolytes stat.

ANS: B Postburn fluid needs are calculated initially by using a standardized formula such as the Parkland formula. However, needs vary among clients, and the final fluid volume needed is adjusted to maintain hourly urine output at 0.5 mL/kg/hr. Based on this client's inadequate urine output, fluids need to be increased. The other orders are appropriate.

23. A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Range of motion in all extremities b. Heart rate, rhythm, and electrocardiogram (ECG) c. Respiratory rate and pulse oximetry d. Orientation to time, place, and person

ANS: B The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes. Range-of-motion and neurologic assessments are important; however, the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs.

12. A client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How does the nurse categorize this injury? a. Full thickness b. Partial thickness superficial c. Partial thickness deep d. Superficial

ANS: B The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters; and pain. Blisters are not seen with full-thickness and superficial burns and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns appear red to white.

34. A client who suffered burns in a house fire reports a headache and is not consistently oriented to time. Which intervention by the nurse is most appropriate? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental Status Examination.

ANS: B These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning.

8. Which statement best exemplifies a client's understanding of rehabilitation after a full-thickness burn injury? a. "I am fully recovered when all the wounds are closed." b. "I will eventually be able to perform all my former activities." c. "My goal is to achieve the highest level of functioning that I can." d. "Full recovery from a major burn injury never occurs."

ANS: C Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

35. A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide before discharge? a. How to maintain home smoke detectors b. Joining a community reintegration program c. Learning to perform dressing changes d. Options available for scar removal

ANS: C Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

22. A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse's best action? a. Administer a laxative. b. Document the finding. c. Prepare to insert a nasogastric (NG) tube. d. Reposition the client on the right side.

ANS: C Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted.

3. The nurse is teaching burn prevention to a community group. Which information shared by a member of the group causes the nurse the greatest concern? a. "I get my chimneys swept every other year." b. "My hot water heater is set at about 120 degrees." c. "Sometimes I wake up at night and smoke." d. "I use a space heater when it gets below zero."

ANS: C House fires are a common occurrence and often lead to serious injury or death. The nurse should be most concerned about a person who wakes up at night and smokes. The nurse needs to question this person about whether he or she gets out of bed to do so, or if this person stays in bed, which could lead to falling back asleep with a lighted cigarette. Although it is recommended to have chimneys swept every year, skipping a year does not pose as much danger as smoking in bed, particularly if the person does not burn wood frequently. Water heaters should be set below 140° F. Space heaters should be used with caution, and the nurse may want to ensure that the person does not allow it to get near clothing or bedding. But the most immediate concern is the person's smoking upon waking up at night.

7. Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? a. Allowing family members to change the dressings b. Discussing future surgical reconstruction c. Performing morning care independently d. Wearing the pressure dressings as ordered

ANS: C Indicators that the client with a burn injury has a positive perception of his appearance include his or her willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications but will not enhance self-perception.

14. A client who is burned is drooling and is having difficulty swallowing. Which action does the nurse take first? a. Assess level of consciousness and pupillary reactions. b. Ascertain the time food or liquid was last consumed. c. Auscultate breath sounds over the trachea and mainstem bronchi. d. Measure abdominal girth and auscultate bowel sounds.

ANS: C Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. Absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important, in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

5. A client with facial burns asks the nurse if he will ever look the same. Which response is best for the nurse to provide? a. "With reconstructive surgery, you can look the same." b. "We can remove the scars with the use of a pressure dressing." c. "You will not look exactly the same but cosmetic surgery will help." d. "You shouldn't start worrying about your appearance right now."

ANS: C Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. The nurse should provide accurate information that includes something to hope for. Pressure dressings prevent further scarring. They cannot remove scars. The client and the family should be taught the expected cosmetic outcomes.

36. An older adult client with burns has a white blood cell count of 10,000/mm3. The client is afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure of 112/68 mm Hg. The client's wound is pale, and edema is noted in the surrounding tissues. Which intervention by the nurse is most appropriate? a. Assess the client's skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

ANS: C Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis. The other options would yield important data but do not take priority over determining whether the client has an infection.

11. A client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding is present, and the client describes just a "small amount of pain." How does the nurse categorize this injury? a. Partial thickness deep b. Partial thickness superficial c. Full thickness d. Superficial

ANS: C The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness burns are deep red to white and painful, and superficial burns are pink to red and are also painful.

17. A client is 24 hours post burn and has the following laboratory results. Which result does the nurse report to the health care provider immediately? a. Arterial pH, 7.32 b. Hematocrit, 52% c. Serum potassium,7.5 mEq/L d. Serum sodium, 131 mEq/L

ANS: C The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.

13. A client with a new burn injury asks the nurse why he is receiving intravenous cimetidine (Tagamet). What is the nurse's best response? a. "Tagamet will stimulate intestinal movement so you can eat more." b. "Tagamet can help prevent hypovolemic shock, which can be fatal." c. "This will help prevent stomach ulcers, which are common after burns." d. "This drug will help prevent kidney damage caused by dehydration."

ANS: C Ulcerative gastrointestinal disease (Curling's ulcer) may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and a decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement and does not prevent hypovolemic shock or kidney damage.

25. The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which action does the nurse perform first? a. Apply silver sulfadiazine (Silvadene) ointment. b. Cover the area with an elastic wrap. c. Place a synthetic dressing over the area. d. Remove loose nonviable tissue.

ANS: D All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process consists of removing exudates and necrotic tissue. This promotes wound healing.

15. On assessment, the nurse notes that a client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse's next action? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for intubation.

ANS: D Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation.

1. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN? a. Administer the prescribed tetanus toxoid vaccine. b. Assess wounds for signs of infection. c. Have the client cough and breathe deeply. d. Wash hands on entering the client's room.

ANS: D Infection can occur when microorganisms from another person or from the environment are transferred to the client. Although all of the interventions listed can help reduce the risk for infection, handwashing is the most effective technique for preventing infection transmission.

27. The family of a client who has been burned asks when the client will no longer be at greater risk for infection. What is the nurse's best response? a. "As soon as the antibiotics have been finished." b. "As soon as albumin levels returns to normal." c. "When fluid remobilization has started." d. "When the burn wounds are closed."

ANS: D Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at high risk for infection as long as any area of skin is open.

19. A client who was burned has crackles in both lung bases and a respiratory rate of 40 breaths/min and is coughing up blood-tinged sputum. Which action by the nurse takes priority? a. Administer digoxin. b. Perform chest physiotherapy. c. Document and reassess in an hour. d. Place the client in an upright position.

ANS: D Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Digoxin may be given later to enhance cardiac contractility to prevent backup of fluid into the lungs. Chest physiotherapy will not get rid of fluid.

24. A client is receiving fluid resuscitation after a burn. Which finding indicates that fluid resuscitation is adequate for this client? a. Hematocrit = 60% b. Heart rate = 130 beats/min c. Increased peripheral edema d. Urine output = 50 mL/hr

ANS: D The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate, as well as laboratory values, to more normal levels.

28. A client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which action by the nurse is most appropriate? a. Continue to monitor the client. b. Increase the temperature in the room. c. Increase the rate of intravenous fluids. d. Prepare to do a workup for sepsis.

ANS: D These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation. The rate of intravenous fluids may be increased to replace fluid losses associated with diarrhea, but this is not the priority action.