Chapter 53: PrepU - Nursing Management: Patients With Burn Injury

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? 1- escharotomy 2- debridement 3- allograft 4- silvadene application

1

A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel? 1- All options are correct. 2- fluid shift 3- fluid loss 4- hypotension

1

A client is scheduled for an allograft to a burn wound, and the client asks for an explanation. What information will the nurse include in the client teaching? 1- "An allograft is a temporary wound covering obtained from cadaver skin." 2- "An allograft is a permanent wound covering taken from a donor site in your body." 3- "An allograft is a temporary wound covering obtained from pig skin." 4- "An allograft is an expensive sheet of skin obtained from a culture."

1

A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury? 1- inflammatory 2- neuroendocrine 3- intravascular fluid excess 4- hypertension

1

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? 1- Risk for Impaired Gas Exchange 2- Acute Pain 3- Risk for Infection 4- Alteration in Tissue Perfusion

1

A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern? 1- BUN: 28 mg/dL 2- K+: 5.0 mEq/L 3- Na+: 145 mEq/L 4- Ca: 9 mg/dL

1

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: 1- dislodge the autografts. 2- increase edema in the arms. 3- increase the amount of scarring. 4- decrease circulation to the fingers.

1

A nurse is reading a journal article about the morbidity and mortality associated with burn injury. The nurse demonstrates understanding of the article by identifying which population as having the highest mortality and morbidity rates? 1- older adults 2- children 3- adolescents 4- young adults

1

A nurse who is contributing to the care of a patient with burns recognizes that the patient's injuries are associated with severe and debilitating pain at nearly all stages of treatment and recovery. What pharmacological intervention is most commonly used in the treatment of burn pain? 1- Intravenous morphine 2- Intravenous hydromorphone (Dilaudid) 3- Oral oxycodone 4- Oral codeine

1

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? 1- Superficial 2- Full-thickness 3- Superficial partial-thickness 4- Deep partial-thickness

1

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? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness

1

A patient has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of their body. What would be the nurse's priority concern in the immediate care of this patient? 1- Fluid status 2- Risk of infection 3- Body image 4- Anxiety

1

A patient has been admitted to the burn unit at a large, tertiary care hospital with burns that involve 35% of the patient's total body surface area (TBSA). The nurse on the burn unit should be aware that: 1- Extensive burns have pathophysiological effects that supersede the integumentary system. 2- Burns involving a large TBSA are often less painful than burns that are less extensive. 3- Extensive burns necessitate palliative care rather than curative treatments. 4- Burns that involve a large TBSA are always accompanied by sepsis.

1

A patient in the emergent/resuscitative phase of a burn injury has had her lab work drawn. Upon analysis of the patient's laboratory studies, the nurse will expect the results to indicate what? 1- Hyperkalemia, hyponatremia, elevated hematocrit, and metabolic acidosis 2- Hypokalemia, hypernatremia, decreased hematocrit, and metabolic acidosis 3- Hyperkalemia, hypernatremia, decreased hematocrit, and metabolic alkalosis 4- Hypokalemia, hyponatremia, elevated hematocrit, and metabolic alkalosis

1

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? 1- 1,200 mL 2- 2,400 mL 3- 3,600 mL 4- 4,800 mL

1

As the first priority of care, a patient with a burn injury will initially need: 1- a patent airway established. 2- an indwelling catheter inserted. 3- fluids replaced. 4- pain medication administered.

1

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: 1- stasis. 2- coagulation. 3- hyperemia. 4- hypotension.

1

Following a burn injury, the nurse determines which area is the priority for nursing assessment? 1- Pulmonary system 2- Cardiovascular system 3- Pain 4- Nutrition

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In a client with burns on the legs, which nursing intervention helps prevent contractures? 1- Applying knee splints 2- Elevating the foot of the bed 3- Hyperextending the client's palms 4- Performing shoulder range-of-motion exercises

1

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? 1- allograft 2- xenograft 3- autograft 4- slit graft

1

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? 1- face, neck, chest 2- perineal 3- hands, major joints 4- All options are correct.

1

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? 1- Roll the client in a blanket. 2- Cover the client with a wet cloth. 3- Place the client with the head positioned slightly below the rest of the body. 4- Avoid immediate IV fluid therapy.

1

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? 1- Electrical burns usually follow an internal path. 2- Lightning is higher in voltage than electricity. 3- The skin is a good conductor of electricity. 4- Moisture intensifies the damage inflicted.

1

Which intervention helps to minimize the risk of further injury to an affected person at the scene of a fire? 1- Roll the client in a blanket 2- Cover the client with a wet cloth 3- Place the client with the head positioned slightly below the rest of the body 4- Avoid immediate IV fluid therapy

1

Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? 1- Reduction in blood volume 2- Sodium excess 3- Potassium deficit 4- Increased urinary output

1

Which of the following is the analgesic of choice for burn pain? 1- Morphine sulfate 2- Fentanyl 3- Demerol 4- Tylenol with codeine

1

Which of the following is the preferred IV fluid for burn resuscitation? 1- Lactated Ringer's (LR) 2- Normal saline (NS) 3- D5W 4- Total parenteral nutrition (TPN)

1

Which of the following measures can be used to cool a burn? 1- Application of cool water 2-Application of ice directly to burn 3- Wrapping the person in ice 4- Using cold soaks or dressings for at least 1 hour

1

Which of the following terms refers to a graft derived from one part of a patient's body and used on another part of that same patient's body? 1- Autograft 2- Allograft 3- Homograft 4- Heterograft

1

Which of the following topical burn preparations act as wick for sodium and potassium? 1- Silver nitrate solution 2- Silver sulfadiazine (Silvadene) 3- Mafenide acetate (Sulfamylon) 4- Acticoat

1

Which term refers to a graft derived from one part of a client's body and used on another part of that same client's body? 1- Autograft 2- Allograft 3- Homograft 4- Heterograft

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Which type of burn injury requires skin grafting? 1- Full-thickness 2- Superficial 3- Superficial partial-thickness 4- Deep partial-thickness

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Which type of burn is similar to a sunburn? 1- Superficial partial-thickness 2- Electrical 3- Deep partial-thickness 4- Full-thickness

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Which zone consists of the area where the injury is most severe and deepest? 1- Coagulation 2- Stasis 3- Hyperemia 4- Necrosis

1

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. 1- "This medication is an antibacterial." 2- "This medication will be applied directly to the wound." 3- "This medication will stain my skin permanently." 4- "This medication will help my burn heal."

1,2,4

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? 1- 18% 2- 27% 3- 36% 4- 45%

2

A client is brought to the emergency department after being involved in a house fire. The client has superficial burns on the arms and legs but emergency medical personnel report that the client may have smoke inhalation. The clent is complaining of a headache and some dizziness. The nurse obtains the client's carboxyhemoglobin level which is 15%. Which action by the nurse would be most appropriate? 1- Have the client take slow deep breaths. 2- Administer 100% oxygen. 3- Give the client a fast-acting bronchodilator. 4- Prepare to intubate the client.

2

A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene? 1- Do nothing until the chemical agent is identified. 2- Irrigate the wounds with water. 3- Wash the wounds with soap and water and apply a barrier cream. 4- Insert a 20-gauge I.V. catheter and infuse normal saline solution at 150 ml/hour.

2

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client? 1- Anemia 2- Gastric ulcers 3- Hyperthyroidism 4- Cardiac arrest

2

A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include 1- monitoring the client for the development of respiratory acidosis. 2- premedicating the client with an analgesic prior to application. 3- monitoring the client's Na+ and K+ serum levels and replace as prescribed. 4- protecting the bed linens and client's clothing from contact to prevent staining.

2

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? 1- Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg 2- Urine output of 20 ml/hour 3- White pulmonary secretions 4- Rectal temperature of 100.6° F (38° C)

2

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: 1- apply maximum bandages to allow for absorption of drainage. 2- wrap elastic bandages distally to proximally on dependent areas. 3- wrap elastic bandages on the arms and legs, proximally to distally, to promote venous return. 4- remove bandages with clean gloves.

2

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? 1- Hyperactive bowel sounds 2- Decreased peristalsis 3- Fecal occult blood 4- Hematemesis

2

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: 1- Epidermal layer only. 2- Epidermis and a portion of deeper dermis. 3- Entire dermis and subcutaneous tissue. 4- Dermis and connective tissue.

2

Acticoat has been ordered as a component of a burn patient's wound care and infection control regimen. When applying this wound care product, the nurse should: 1- Allow the Acticoat to dry thoroughly before covering it with a dry dressing. 2- Moisten the Acticoat with sterile water and then apply it to the wound bed. 3- Use a pad of Acticoat to perform mechanical debridement. 4- Change the dressing every 18 to 24 hours.

2

After burning herself by turning off the cold water of her bath, a 3-year-old girl has been brought to the emergency department (ED) with burns that have been assessed as superficial partial-thickness. The ED nurse should recognize which of the following characteristics of this child's burn? 1- The burn is likely to require a skin graft in order to facilitate full healing. 2- The child's burn will heal spontaneously in approximately 1 week and is unlikely to scar. 3- The child will require admission to a burn unit and aggressive treatment to prevent complications. 4- The child's burn involves the epidermis but the dermis is unaffected.

2

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? 1- The client is in hypovolemic shock. 2- The client has experienced extensive full-thickness burns. 3- The paramedic administered high doses of opioids during transport. 4- The client has experienced partial-thickness burns.

2

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? 1- A urinary output of 10 mL/hr 2- A urinary output of 30 mL/hr 3- A urinary output of 80 mL/hr 4- A urinary output of 100 mL/hr

2

The nursing care plan of a patient who is in the acute/immediate phase of burn care identifies a nursing diagnosis of Risk for Infection due to burns. What intervention should be prioritized in response to this diagnosis? 1- Intravenous administration of broad-spectrum, prophylactic antibiotics 2- Vigilant application of infection-control precautions such as gloves, gowns, and masks 3- Administration of oral prophylactic antibiotics 4- Regular disinfecting of the patient's intact skin and the immediate bedside environment

2

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? 1- Rule of nines 2- Use client's palm size 3- Parkland formula 4- Lund and Browder burns assessment

2

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area? 1- Prevent infection 2- Fluid resuscitation 3- Endotracheal tube placement 4- Strict intake and output

2

Which of the following is a disadvantage of surgical debridement? 1- Scarring 2- Bleeding 3- Loss of function 4- Contractures

2

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? 1- Superficial partial thickness 2- Deep partial-thickness 3- Full-thickness 4- Fourth degree

2

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first? 1- Albumin 2- Dextrose 5% in water (D5W) 3- Lactated Ringer's solution 4- Normal saline solution with 20 mEq of potassium per 1,000 ml

3

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: 1- Reddened; blanches with pressure. 2- Blistered with a mottled red base. 3- Dry and pale white. 4- Broken epidermis that is weeping.

3

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? 1- Removal of clothing 2- Irrigation of the wound 3- Application of ice 4- Removal of hair

3

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? 1- Cerium nitrate solution 2- Gentamicin sulfate 3- Sulfadiazine, silver (Silvadene) 4- Mafenide (Sulfamylon)

3

The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse? 1- The wound will take up to 3 weeks to heal. 2- Pain management will be a challenge. 3- Skin grafting will be necessary. 4- Ligaments, tendons, muscles, and bone are not involved.

3

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? 1- 18% 2- 27% 3- 30% 4- 36%

4

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? 1- "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." 2- "I will drink a lot of fluids to prevent constipation since I am taking pain medications." 3- "As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help." 4- "I can work with the social worker to find funding assistance programs to help with my medical expenses."

3

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? 1- Hypernatremia 2- Hypokalemia 3- Hyperkalemia 4- Hypercalcemia

3

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? 1- Cerium nitrate solution 2- Gentamicin sulfate 3- Sulfadiazine, silver (Silvadene) 4- Mafenide (Sulfamylon)

3

The triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What would the nurse in the ED receiving the call instruct the father to do? 1- Cover the burn with ice and secure with a towel. 2- Apply skin lotion to the area that is burned. 3- Immerse the child in a cool bath. 4- Avoid touching the burned area in any way.

3

To meet early nutritional demands for protein, a 198-lb (90-kg) burned patient will need to ingest a minimum of how much protein every 24 hours? 1- 90 g/day 2- 110 g/day 3- 180 g/day 4- 270 g/day

3

Which of the following is a true statement regarding the purposes of skin grafts? 1- Increases evaporative fluid loss. 2- Increases potential for infection. 3- Reduces scarring and contractures. 4- Prolongs recovery

3

A 44-year-old man has suffered severe electrical burns while working on an infrastructure project. Rapid assessment at the scene of the accident reveals that he has burns to his entire lower body and is currently unconscious. What is the priority action in the immediate care of this patient? 1- Cooling the patient's burns 2- Establishing intravenous access 3- Covering the patient's burns with sterile gauze 4- Maintaining a patent airway

4

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? 1- full thickness (third degree) 2- superficial (first degree) 3- superficial partial-thickness or deep partial-thickness (second degree) 4- fourth degree

4

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? 1- It helps determine the percentage of the total body surface area (TBSA) that is burned. 2- The client's condition is likely to deteriorate after 72 hours. 3- The wound is susceptible to infections. 4- The early appearance of the burn injury may change.

4

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: 1- fluid resuscitation. 2- infection. 3- body image. 4- pain management.

4

A male patient is brought to the emergency department (ED) from the site of a chemical fire. The paramedics report that the patient has a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. When the nurse assesses the patient, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patient's right arm? 1- Superficial partial-thickness 2- Deep partial-thickness 3- Full partial-thickness 4- Full-thickness

4

A nurse is preparing a care plan for a client burned over 36% of his body 2 days ago. Which clinical manifestation indicates that the client has progressed into the intermediate phase of burn care? 1- The client's serum sodium levels are elevated. 2- The client exhibits metabolic alkalosis. 3- The client's urinary output has fallen below 30 ml/hour. 4- The client's complete blood count readings reflect a reduced hematocrit.

4

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? 1- 9% 2- 18% 3- 27% 4- 36%

4

Following a serious thermal burn, which complication will the nurse take action to prevent first? 1- Tissue hypoxia 2- Infection 3- Renal failure 4- Hypovolemia

4

The emergency department nurse has just admitted a patient with a burn. The nurse recognizes that the patient is likely to require a nasogastric tube when the burn exceeds a total body surface area (TBSA) of what percentage? 1- 10% 2- 15% 3- 20% 4- 25%

4

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 1- increased metabolic rate. 2- increased glucose demands. 3- increased skeletal muscle breakdown. 4- decreased catabolism.

4

The nurse cares for a client in the burn unit. What is an early sign of sepsis in the client with burn injury? 1- Hyperthermia 2- Decreased pulse rate 3- Clammy skin 4- Narrowing pulse pressure

4

The nurse is caring for a patient who sustained a deep partial-thickness burn injury 36 hours ago. In prioritizing the nursing diagnoses for the plan of care, the nurse will give the highest priority to which of the following nursing diagnoses? 1- Activity intolerance 2- Anxiety 3- Impaired nutrition: less than body requirements 4- Acute pain

4

The occupational health nurse is called to the floor of the factory where a patient has sustained a flash burn to the right arm. The nurse arrives and the flames have been extinguished. The next step is to "cool the burn." How should the nurse cool the burn? 1- Apply ice to the site of the burn for 5 to 10 minutes. 2- Wrap the patients affected extremity in ice until help arrives. 3- Apply an oil-based substance or butter to the burned area until help arrives. 4- Wrap cool towels around the affected extremity intermittently.

4

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately? 1- Complaints of intense thirst 2- Moderate to severe pain 3- Urine output of 70 ml the first hour 4- Hoarseness of the voice

4

Which of the following types of shock will a nurse observe in a client with extensive burns? 1- Anaphylactic shock 2- Neurogenic shock 3- Septic shock 4- Hypovolemic shock

4