Chapter 57: Management of Patients with 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 burns associated with chemicals used in the plant?"
The nurse has completed teaching home care instructions to a client being discharged from the burn unit. Which statement from the client indicates the need for further teaching?
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."
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
A nurse provides care for a client with deep partial-thickness burns 48 hours after the burn. What would cause a reduced hematocrit in this client?
Hemodilution
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
Hypovolemia
The nurse is caring for a client with burns over 55% of total body surface area. Which information is essential for the nurse to document to guide the care of this client? Select all that apply.
Pre-burn body weight Current list of medications Last tetanus immunization Current body temperature
A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?
The client's urinary output is 0.5 to 1 mL/kg/hour.
Which is the primary reason for placing a client in a horizontal position while smothering flames are present?
To keep fire and smoke from airway
A client received burns to his entire back and left arm. Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?
27%
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which time frame?
5 days
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
Which type of burn injury requires skin grafting?
full thickness
A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?
gastric ulcers
A client with a burn wound is prescribed mafenide acetate 5% twice daily. Nursing implications associated with this medication include
premedicating the client with an analgesic prior to application.
Which of the following is a potential cause of a superficial partial-thickness burn?
sunburn
A client is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?
36%
A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?
Homografts
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
A client has been burned significantly in a workplace accident. Which conditions create the need for immediate intensive care by specifically trained personnel? Select all that apply.
hypotension fluid loss fluid shift
A child tips a pot of boiling water onto his bare legs. The mother should:
immerse the child's legs in cool water
A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in urgent care. The nurse's primary concern should be:
pain management.
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
A sample consensus formula for fluid replacement recommends that a balanced salt solution be administered in the first 24 hours of a chemical burn in the range of 2 mL/kg/% of burn, with 50% of the total given in the first 8 hours postburn. A 176-lb (80-kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2,400 ml/h
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
36%
A sample consensus formula for fluid replacement recommends that an isotonic solution be administered in the first 24 hours of a burn in the range of 2 to 4 mL/kg/% of burn with 50% of the total given in the first 8 hours postburn. A 176 lb (80 kg) man with a 30% burn should receive a minimum of how much fluid replacement in the first 8 hours?
2,400 m/L
The nurse is planning the care of a patient with a major thermal burn. What outcome will the nurse understand will be optimal during fluid replacement?
A urinary output of 30 mL/hr
The spouse of a client who was struck by lightning asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?
Electrical burns usually follow an internal path.
A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse describes the skin involvement as the:
Epidermis and a portion of deeper dermis.
The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply.
Sodium deficit Elevated hematocrit level Base-bicarbonate deficit
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 help my burn heal." "This medication will be applied directly to the wound."
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client
fluid resuscitation
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
Skin grafts are necessary for what type of burn?
full thickness
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
intravenous
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
pulmonary system
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
replace lost fluid and electrolytes
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
At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Select all that apply.
roll the client in a blanket have the pt lay horizontally
Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply.
singed nasal hair facial burns hoarseness
In a client with burns on the legs, which nursing intervention helps prevent contractures?
applying knee splints
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?
180
A client has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery?
2 to 5 days after surgery
Which of the following measures can be used to cool a burn?
Application of cool water
Which of the following skin substitutes is a nylon-silicone membrane coated with a protein?
Biobrane
Which of the following is a common complication of an electrical burn injury?
Cardiac dysrhythmias
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis as well as injury to the deeper portions of the dermis?
Deep partial-thickness
A client recovering from burn injuries over both forearms reports itching of the wounds. Which action will the nurse take to enhance the client's comfort?
Instruct to pat and not scratch the areas.
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
Which of the following is the preferred IV fluid for burn resuscitation?
Lactated Ringer's (LR)
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?
Lactated Ringer's solution
A young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
Lund and Browder method
The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain?
Music therapy may provide reality orientation, distraction, and sensory stimulation.
The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?
Paralytic ileus
A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?
Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel.
The nurse is caring for a client 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 if it occurs immediately after burn injury?
Hyperkalemia
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.
Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Which graft is described as a biologic source of skin similar to that of the client?
allograft
The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.
daily weights hourly urine output skin turgor
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
decrease catabolism
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.