Chapter 62: Management of Patients with Burn Injury

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? A.) Electrical burns usually follow an internal path. B.) Lightning is higher in voltage than electricity. C.) The skin is a good conductor of electricity. D.) Moisture intensifies the damage inflicted.

Answer: A.) Electrical burns usually follow an internal path. Rationale: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high-voltage electricity. Presence of water acts as a conductor of electrical current.

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

Answer: B.) Applying knee splints Rationale: Applying knee splints is one method which can help prevent 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 which is the focus for this individual's treatment and care.

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: A.) Epidermal layer only. B.) Epidermis and a portion of deeper dermis. C.) Entire dermis and subcutaneous tissue. D.) Dermis and connective tissue.

Answer: B.) Epidermis and a portion of deeper dermis. Rationale: 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.

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

Answer: B.) Hyperkalemia. Rationale: 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 the analgesic of choice for burn pain? A.) Tylenol with codeine B.) Morphine sulfate C.) Fentanyl D.) Demerol

Answer: B.) Morphine sulfate Rationale: Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient's self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain.

Which type of debridement occurs when nonliving tissue sloughs away from uninjured tissues? A.) Mechanical B.) Natural C.) Enzymatic D.) Surgical

Answer: B.) Natural Rationale: 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.

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? A.) The client is in hypovolemic shock. B.) The client has experienced extensive full-thickness burns. C.) The paramedic administered high doses of opioids during transport. D.) The client has experienced partial-thickness burns.

Answer: B.) The client has experienced extensive full-thickness burns. Rationale: 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? A.) The client's heart rate is rapid. B.) The client's urinary output is 0.5 mL/kg/hour. C.) The client's breathing is unlabored and skin is clammy. D.) The client is conscious.

Answer: B.) The client's urinary output is 0.5 mL/kg/hour. Rationale: 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.

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

Answer: D.) Hoarseness of the voice Rationale: 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 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? A.) Face only B.) Face, neck, and chest C.) Face and neck D.) Neck and chest

Answer: D.) Neck and chest Rationale: 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.

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? A.) Full-thickness B.) Superficial C.) Superficial partial-thickness D.) Deep partial-thickness

Answer: A.) Full-thickness Rationale: 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 from a full-thickness burn. It is red or white, mottled, and can be moist or fairly dry.

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

Answer: B.) Application of cool water Rationale: 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.

What laboratory value observed by the nurse is unexpected during the fluid remobilization phase of a major burn? A.) Hematocrit level of 45% B.) A pH of 7.20, PaO2 of 38 mm Hg, and bicarbonate level of 15 mEq/L C.) Serum potassium level of 3.2 mEq/L D.) Serum sodium level of 140 mEq/L

Answer: D.) Serum sodium level of 140 mEq/L Rationale: In the acute/intermediate (fluid remobilization) phase of burn care, sodium is lost with water due to diuresis, and existing serum sodium is diluted with water influx, resulting in a decreased serum sodium level. Normal serum sodium level is 135 to 145 mEq/L, so 140 mEq/L is a normal finding, which is unexpected in the acute/intermediate phase of burn care. Normal hematocrit, metabolic acidosis, and hypokalemia are all expected findings during this phase.

Which zone consists of the area where the injury is most severe and deepest? A.) Coagulation B.) Stasis C.) Hyperemia D.) Necrosis

Answer: A.) Coagulation Rationale: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

The nurse is monitoring for fluid and electrolyte changes in the emergent phase of burn injury for a patient. Which of the following will be an expected outcome? Select all that apply. - Base-bicarbonate deficit - Elevated hematocrit level - Potassium deficit - Sodium deficit - Magnesium deficit

Answer: - Base-bicarbonate deficit - Elevated hematocrit level - Sodium deficit Rationale: At the time of burn injury, some red blood cells may be destroyed and others damaged, resulting in anemia. Despite this, the hematocrit may be elevated due to plasma loss. Immediately after burn injury, hyperkalemia (excessive potassium) may result from massive cell destruction. Hyponatremia (serum sodium depletion) may be present as a result of plasma loss. There is a loss of bicarbonate ions accompanying sodium loss, which results in metabolic acidosis (base-bicarbonate deficit).

The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply. - Hourly urine output - Daily weights - Percentage of meals eaten - Skin turgor - Oxygen saturation

Answer: - Hourly urine output - Daily weights - Skin turgor Rationale: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Skin turgor is a sign of fluid loss (dehydration). Percentage of meals eaten, and oxygen saturation would not be reliable indicators of fluid volume status in the client.

When using the Palmer method to estimate the extent of the burn injury, the nurse determines the palm is equal to which percentage of total body surface area? A.) 1 B.) 2 C.) 3 D.) 4

Answer: A.) 1 Rationale: 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 client's palm, including the surface area of the digits, is approximately 1% of the total body surface area.

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

Answer: A.) BUN: 28 mg/dL Rationale: 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.

The nurse determines which statement reflects current research regarding the utilization of nonpharmacological measures in the management of burn pain? A.) Music therapy may provide reality orientation, distraction, and sensory stimulation. B.) Music therapy diverts the client's attention toward painful stimulus. C.) Humor therapy has not proven effective in the management of burn pain. D.) Pet therapy has proven effective in the management of burn pain.

Answer: A.) Music therapy may provide reality orientation, distraction, and sensory stimulation. Rationale: Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the client's attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It allows for client self-expression. Humor therapy has proven effective in the management of burn pain. Pet therapy has not proven effective in the management of burn pain.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? A.) Pulmonary system B.) Cardiovascular system C.) Pain D.) Nutrition

Answer: A.) Pulmonary system Rationale: 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.

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? A.) Roll the client in a blanket. B.) Cover the client with a wet cloth. C.) Place the client with the head positioned slightly below the rest of the body. D.) Avoid immediate IV fluid therapy.

Answer: A.) Roll the client in a blanket. Rationale: 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.

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? A.) Superficial B.) Full-thickness C.) Superficial partial-thickness D.) Deep partial-thickness

Answer: A.) Superficial Rationale: 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.

As the first priority of care, a patient with a burn injury will initially need: A.) a patent airway established. B.) an indwelling catheter inserted. C.) fluids replaced. D.) pain medication administered.

Answer: A.) a patent airway established. Rationale: Breathing must be assessed and a patent airway established immediately during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen.

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? A.) allograft B.) xenograft C.) autograft D.) slit graft

Answer: A.) allograft Rationale: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client's own skin, transplanted from one part of the body to another. A slit graft is a type of autograft.

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: A.) dislodge the autografts. B.) increase edema in the arms. C.) increase the amount of scarring. D.) decrease circulation to the fingers.

Answer: A.) dislodge the autografts. Rationale: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

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? A.) full thickness (third degree) B.) superficial (first degree) C.) superficial partial-thickness or deep partial-thickness (second degree) D.) fourth degree

Answer: A.) full thickness (third degree) Rationale: 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 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? A.) 1,200 mL B.) 2,400 mL C.) 3,600 mL D.) 4,800 mL

Answer: B.) 2,400 mL

A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned? A.) 18% B.) 27% C.) 36% D.) 45%

Answer: B.) 27%

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

Answer: C.) "Are the burns associated with chemicals used in the plant?" Rationale: 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.

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? A.) 9% B.) 18% C.) 27% D.) 36%

Answer: C.) 27% Rationale: 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.

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

Answer: C.) Contact the primary care provider and prepare for an escharotomy. Rationale: 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 requires skin grafting? A.) Superficial B.) Superficial partial-thickness C.) Full-thickness D.) Deep partial-thickness

Answer: C.) Full-thickness Rationale: A full-thickness burn injury heals by contraction or epithelial migration and requires grafting. The other types of burn injury do not require skin grafting.

When a client is receiving 100% oxygen, what is the key sign of onset of acute respiratory distress syndrome? A.) Tachypnea B.) Stridor C.) Hypoxemia D.) Chest pain

Answer: C.) Hypoxemia Rationale: 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.

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? A.) Diverticulitis B.) Hematemesis C.) Paralytic ileus D.) Ulcerative colitis

Answer: C.) Paralytic ileus Rationale: Patients who are critically ill, including those with burns, are predisposed to altered gastrointestinal (GI) motility for many reasons, which may include impaired enteric nerve and smooth muscle function, inflammation, surgery, medications, and impaired tissue perfusion. Three of the most common GI alterations in burn-injured patients are paralytic ileus (absence of intestinal peristalsis), Curling's ulcer, and translocation of bacteria. Decreased peristalsis and bowel sounds are manifestations of paralytic ileus.

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? A.) Age B.) Weight C.) Preexisting conditions D.) Family history

Answer: C.) Preexisting conditions Rationale: 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.

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? A.) 9% B.) 18% C.) 27% D.) 36%

Answer: D.) 36% Rationale: 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 that have 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? A.) 18% B.) 27% C.) 30% D.) 36%

Answer: D.) 36% Rationale: 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.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein? A.) Mederma B.) Integra C.) Transcyte D.) Biobrane

Answer: D.) Biobrane Rationale: Biobrane is a nylon-silicone membrane coated with a protein. Mederma is 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.

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

Answer: D.) The early appearance of the burn injury may change. Rationale: 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.