Chapter 66: Caring for Clients with Burns

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? a. Partial pressure of arterial oxygen (PaO2) value of 80 mm Hg b. Urine output of 20 ml/hour c. White pulmonary secretions d. Rectal temperature of 100.4° F (38° C)

b A urine output of less than 30 ml/hour in a client with burns indicates a deficient fluid volume. This client's PaO2 value falls within the normal range (80 to 100 mm Hg). White pulmonary secretions are normal. The client's rectal temperature isn't significantly elevated, and the slight increase in temperature probably results from the deficient fluid volume.

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? a. escharotomy b. debridement c. allograft d. silvadene application

a 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 nurse is caring for a client with burns who is in the later stages of the acute phase of recovery. The plan of nursing care should include which of the following nursing actions? a. Maintenance of bed rest to aid healing b. Choosing appropriate splints and functional devices c. Administration of beta adrenergic blockers d. Prevention of venous thromboembolism

d Prevention of deep vein thrombosis (DVT) is an important factor in care. Early mobilization of the client is important. The nurse monitors the splints and functional devices, but these are selected by occupational and physical therapists. The hemodynamic changes accompanying burns do not normally require the use of beta blockers.

The nurse is instructing a client using a pressure garment after a burn. For how many hours each day at a minimum will the nurse advise the client to wear the device? Fill in the blank with a number.

23

A client has experienced burns covering the back and front of both legs. Using the Rule of Nines, what percentage would the nurse assign to the client's injury when documenting? Fill in the blank with a number.

36

Which is a quick technique to assess the percentage of a burn injury? a. comparing the client's palm with the size of the burn wound b. observing the client's level of consciousness c. observing the color of the client's wound d. checking the client's vital signs

a A quick technique to assess the percentage of burn injury is to compare the client's palm with the size of the burn wound. The palm is approximately 1% of a person's TBSA.

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.

a 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.

When caring for a client with burns, a nurse should change the wound dressing at least once every: a. day. b. two hours. c. three days. d. week.

a When caring for a client with burns, the nurse should change the wound dressing at least once a day to minimize the pain and monitor the wound to determine any infection. More frequent dressing changes occur when the wound is infected or when there is a significant saturation with wound exudates.

A client with severe burns is admitted to the intensive care unit to stabilize and begin fluid resuscitation before transport to the burn center. The nurse should monitor the client closely for what signs of the onset of burn shock? a. Confusion b. High fever c. Decreased blood pressure d. Sudden agitation

c As fluid loss continues and vascular volume decreases, cardiac output continues to decrease and the blood pressure drops, marking the onset of burn shock. Shock and the accompanying hemodynamic changes are not normally accompanied by confusion, fever, or agitation.

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? a. 90 g/day b. 110 g/day c. 180 g/day d. 270 g/day

c Recommendations from recent literature advocate protein requirements of 1.5 to 2 g/kg/day (Saffle, Graves, & Cochran, 2012).

A nurse is developing a care plan for a client with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention? a. To prevent neuropathies b. To prevent wound breakdown c. To prevent contractures d. To prevent heterotopic ossification

c To prevent the complication of contractures, the nurse will establish a goal to maintain position of joints in alignment. Gentle range-of-motion exercises and a consult to PT and OT for exercises and positioning recommendations are also appropriate interventions for the prevention of contractures. Joint alignment is not maintained specifically for preventing neuropathy, wound breakdown, or heterotopic ossification.

Which of the following is a potential cause of a superficial partial-thickness burn? a. Sunburn b. Scald c. Flash flame d. Electrical current

a A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids.

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? a. Moisten with sterile water only. b. Moisten with saline. c. Use topical antimicrobials with Acticoat burn dressing. d. Keep Acticoat saturated.

a Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated.

A client is admitted to the burn unit after being transported from a facility a large distance away. The client has burns to the groin area and circumferential burns to both upper thighs. When assessing the client's legs distal to the wound site, the nurse should be cognizant of the risk of what complication? a. Ischemia b. Referred pain c. Cellulitis d. Venous thromboembolism (VTE)

a As edema increases, pressure on small blood vessels and nerves in the distal extremities causes an obstruction of blood flow and consequent ischemia. This complication is similar to compartment syndrome. Referred pain, cellulitis, and VTE are not noted complications that occur distal to the injury site.

How many people die of burn injuries each year in the United States? a. 3300 b. 5500 c. 1250 d. 2600

a The American Burn Association (2016) estimates that 3275 people die from burns each year. Thus, 3300 deaths is the closest approximation.

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? a. 1,200 mL b. 2,400 mL c. 3,600 mL d. 4,800 mL

b The minimum replacement is 2 mL/kg/%. Therefore, 2 mL × 80 kg = 160 mL × 30% = 4,800 mL. To give 50% in the first 8 hours, the nurse would give 2,400 mL.

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. a. Wound care b. Nutritional support c. Fluid loss d. Fluid shift e. Hypotension

c, d, e Fluid shift, fluid loss, and hypotension can lead to irreversible shock. These changes usually happen rapidly and the client's status may change from hour to hour, requiring that clients with burns receive intensive care by skilled personnel. Wound care and nutritional support are important, but not immediate, client needs.

A nurse formulates a nursing diagnosis of Impaired physical mobility for a client with full-thickness burns on the lower portions of both legs. To complete the nursing diagnosis statement, the nurse should add which "related-to" phrase? a. Related to fat emboli b. Related to infection c. Related to femoral artery occlusion d. Related to circumferential eschar

d As edema develops on circumferential burns, eschar forms a tight, constricting band, compromising circulation to the extremity distal to the circumferential site and impairing physical mobility. This client isn't likely to develop fat emboli unless long bone or pelvic fractures are present. Infection doesn't alter physical mobility. A client with burns on the lower portions of both legs isn't likely to have femoral artery occlusion.

An occupational health nurse is called to the floor of a factory where a worker 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? a. Apply ice to the site of the burn for 5 to 10 minutes. b. Wrap the client's affected extremity in ice until help arrives. c. Apply an oil-based substance to the burned area until help arrives. d. Wrap cool towels around the affected extremity intermittently.

d Once the burn has been sustained, the application of cool water is the best first-aid measure. Soaking the burn area intermittently in cool water or applying cool towels gives immediate and striking relief from pain, and limits local tissue edema and damage. However, 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. Oils are contraindicated.

Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent? a. Cerium nitrate solution b. Gentamicin sulfate c. Sulfadiazine, silver (Silvadene) d. Mafenide (Sulfamylon)

c All topical antibacterial agents for burn wounds have associated nursing implications. Leukopenia is a side effect found with Silvadene. Refer to Table 53-5 in the text.

Specific potential complications are common to specific types of burns. Which burns can impair ventilation? a. face, neck, chest b. perineal c. hands, major joints d. legs

a Burns of the face, neck, or chest have the potential to impair ventilation due to their proximity to the areas where breathing occurs.

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? a. "An allograft is a temporary wound covering obtained from cadaver skin." b. "An allograft is a permanent wound covering taken from a donor site in your body." c. "An allograft is a temporary wound covering obtained from pig skin." d. "An allograft is an expensive sheet of skin obtained from a culture."

a There are several different temporary and permanent coverings for burn wounds. 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 client. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body's immune response will eventually reject them as a foreign substance.

Which of the following is the analgesic of choice for burn pain? a. Morphine sulfate b. Fentanyl c. Demerol d. Tylenol with codeine

a 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.

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? a. Establish a patent airway. b. Insert an indwelling catheter. c. Replace fluids. d. Administer pain medication.

a 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.

A client who was severely burned begins to exhibit symptoms of renal failure during treatment. What physiologic process can cause acute renal failure? a. hemoconcentration b. anemia c. fluid, electrolyte status d. histamine

a The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure.

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: a. stasis. b. coagulation. c. hyperemia. d. hypotension.

a 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 type of burn injury requires skin grafting? a. Full-thickness b. Superficial c. Superficial partial-thickness d. Deep partial-thickness

a 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.

A public health nurse has reviewed local data about the incidence and prevalence of burn injuries in the community. These data are likely to support what health promotion effort? a. Education about home safety b. Education about safe storage of chemicals c. Education about workplace health threats d. Education about safe driving

a A large majority of burns occur in the home setting; educational interventions should address this epidemiologic trend.

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

a 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.

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? a. Have someone assist him into a bath of cool water, where he can soak intermittently while waiting for emergency personnel. b. Lie down, have someone cover him with a blanket, and cover his legs with petroleum jelly. c. Remove his burned pants so that the air can help cool the wound. d. Sit in a chair, elevate his legs, and have someone cut his pants off around the burned area.

a After the flames are extinguished, the burned area and adherent clothing are soaked with cool water, briefly, to cool the wound and halt the burning process.

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

a 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.

a 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.

Within the burn unit, clients may develop complications based on the type of burn they endured. Which burns have a common complication of cardiac dysrhythmias? a. electrical b. thermal c. chemical d. heat

a Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns.

A client has been admitted to a burn intensive care unit with extensive full-thickness burns over 25% of the body. After ensuring cardiopulmonary stability, what would be the nurse's immediate, priority concern when planning this client's care? a. Fluid status b. Risk of infection c. Nutritional status d. Psychosocial coping

a During the early phase of burn care, the nurse is most concerned with fluid resuscitation, to correct large-volume fluid loss through the damaged skin. Infection control and early nutritional support are important, but fluid resuscitation is an immediate priority. Coping is a higher priority later in the recovery period.

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. A urine output consistently above 40 ml/hour b. A weight gain of 4 lb (2 kg) in 24 hours c. Body temperature readings all within normal limits d. An electrocardiogram (ECG) showing no arrhythmias

a 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.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period? a. Administer IV fluids b. Administer broad-spectrum antibiotics c. Administer IV potassium chloride d. Administer packed red blood cells

a Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally given. Potassium chloride would exacerbate the client's hyperkalemia.

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

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

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

a 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.

An emergency department nurse learns from the paramedics that the team is transporting a client who has suffered injury from a scald from a hot kettle. What variables will the nurse consider when determining the depth of burn? a. The causative agent b. The client's pre-injury health status c. The client's prognosis for recovery d. The circumstances of the accident

a The following factors are considered in determining the depth of a burn: how the injury occurred, causative agent (such as flame or scalding liquid), temperature of the burning agent, duration of contact with the agent, and thickness of the skin. The client's pre-injury status, circumstances of the accident, and prognosis for recovery are important, but are not considered when determining the depth of the burn.

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. What pain management strategy is most likely to meet this client's needs? a. A patient-controlled analgesia (PCA) system b. Oral opioids supplemented by NSAIDs c. Distraction and relaxation techniques supplemented by NSAIDs d. A combination of benzodiazepines and topical anesthetics

a The goal of treatment is to provide a long-acting analgesic that will provide even coverage for this long-term discomfort. It is helpful to use escalating doses when initiating the medication to reach the level of pain control that is acceptable to the client. The use of patient-controlled analgesia (PCA) gives control to the client and achieves this goal. Clients cannot normally achieve adequate pain control without the use of opioids, and parenteral administration is usually required.

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

a The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury.

A patient has been prescribed mafenide acetate cream for burn treatment. The nurse should educate the patient regarding which of the following? a. Severe burning pain for up to 20 minutes b. Stains clothing c. Can be left in place for 3 to 5 days d. Blood levels of sodium and potassium will be monitored.

a The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored.

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.

a 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 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

a 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.

A client has a skin graft and is also using a pressure garment as part of the recovery following a burn injury. Which of the following measures would the nurse advise the client to follow? a. Use a sunscreen with a high SPF while outdoors to protect against pigment changes. b. Apply Mederma to the skin once or twice a week to reduce scarring. c. After washing the garment, use a clothes dryer to dry it and remove all moisture. d. Remove the garment regularly for 1 or 2 hours to allow the graft to breathe.

a The nurse would correctly advise the client to use sunscreen with a high sun protection factor (SPF) when outdoors to prevent permanent pigment changes in the healing skin. While scarring can be reduced by applying Mederma, a topical gel, to the skin, the client needs to use it 3 to 4 times a day, not once or twice a week. After handwashing the garment, the client should hang it to dry at room temperature away from direct heat, and should not use a clothes dryer. The client needs to wear the garment 23 hours each day.

The closed method is the current preferred method of wound management for many reasons. What is not one of those reasons? a. It leads to the formation of a hard crust over a burn. b. It creates a microbial barrier. c. It reduces heat loss through evaporation. d. It provides a moist environment that facilitates healing.

a The open method results in formation of a hard crust over a burn. The reasons the closed method is preferred are that it creates a microbial barrier; it reduces heat loss through evaporation; and it provides a moist environment that facilitates healing.

The open method (exposure method) of burn care, which exposes the burned areas to air, has been virtually abandoned since the advent of effective topical antimicrobials. It is still used on a small scale however. On which areas of the body are burns still being treated this way? Select all that apply. a. The face b. The perineum c. The chest d. The legs

a, b The open method is still being used with the face and the perineum.

Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. a. Singed nasal hair b. Hoarseness c. Facial burns d. Yellow sputum e. Bradypnea

a, b, c Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea.

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. a. "This medication is an antibacterial." b. "This medication will be applied directly to the wound." c. "This medication will stain my skin permanently." d. "This medication will help my burn heal."

a, b, d 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.

A client is in the acute phase of a burn injury. One of the nursing diagnoses in the plan of care is Ineffective Coping Related to Trauma of Burn Injury. What interventions appropriately address this diagnosis? Select all that apply. a. Promote truthful communication. b. Avoid asking the client to make decisions. c. Teach the client coping strategies. d. Administer benzodiazepines as prescribed. e. Provide positive reinforcement.

a, c, e The nurse can assist the client to develop effective coping strategies by setting specific expectations for behavior, promoting truthful communication to build trust, helping the client practice appropriate strategies, and giving positive reinforcement when appropriate. The client may benefit from being able to make decisions regarding his or her care. Benzodiazepines may be needed for short-term management of anxiety, but they are not used to enhance coping.

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

b 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 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

b The ABA consensus formula provides for the volume of an isotonic solution (e.g., lactated Ringer's [LR]) to be administered during the first 24 hours in a range of 2 mL/kg/percentage TBSA. Half of the calculated total should be given over the first 8 postburn hours, and the other half should be given over the next 16 hours. Thus, the equation to find the minimum amount to infuse for this scenario is as follows: 2 mL × 80 kg × 30 = 4,800 mL of solution to be administered in the first 24 hours, with half this amount, 2,400 mL, to be administered in the first 8 hours.

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.

b 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.

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? a. Superficial partial thickness b. Deep partial-thickness c. Full-thickness d. Fourth degree

b 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 client's burns have required a homograft. During the nurse's most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurse's most appropriate response? a. Perform mechanical débridement to remove the exudate and prevent further infection. b. Inform the primary care provider promptly because the graft may need to be removed. c. Perform range-of-motion exercises to increase perfusion to the graft site and facilitate healing. d. Document this finding as an expected phase of graft healing.

b An infected graft may need to be removed, thus the care provider should be promptly informed. ROM exercises will not resolve this problem and the nurse would not independently perform débridement.

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. A urinary output of 10 mL/hr b. A urinary output of 30 mL/hr c. A urinary output of 80 mL/hr d. A urinary output of 100 mL/hr

b 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).

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

b Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the client is an appropriate intervention. The other nursing implications are not associated with mafenide.

A home care nurse is performing a visit to a client's home to perform wound care following the client's hospital treatment for severe burns. While interacting with the client, the nurse should assess for evidence of what complication? a. Psychosis b. Posttraumatic stress disorder c. Delirium d. Vascular dementia

b Posttraumatic stress disorder (PTSD) is the most common psychiatric disorder in burn survivors, with a prevalence that may be as high as 45%. As a result, it is important for the nurse to assess for this complication of burn injuries. Psychosis, delirium, and dementia are not among the noted psychiatric and psychosocial complications of burns.

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.

c 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.

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%

c 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.

A 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 should the nurse in the ED receiving the call instruct the father to do? a. Cover the burn with ice and secure with a towel. b. Apply butter to the area that is burned. c. Immerse the child in a cool bath. d. Avoid touching the burned area under any circumstances.

c After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

A client has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action? a. Instruct the client to keep the wound site in a dependent position b. Administer PRN analgesia as prescribed c. Assess the client's peripheral pulses distal to the dressing d. Assist with passive range-of-motion exercises to "set" the new dressing

c Dressings can impede circulation if they are wrapped too tightly. The peripheral pulses must be checked frequently and burned extremities elevated. Dependent positioning does not need to be maintained. PRN analgesics should be given prior to the dressing change. ROM exercises do not normally follow a dressing change.

Which zone of burn injury sustains the most damage? a. Outer b. Middle c. Inner d. Protective

c Each burned area has three zones of injury. The inner area (known as the zone of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage.

A nurse is teaching a client with a partial-thickness wound how to wear his elastic pressure garment. How should the nurse instruct the client to wear this garment? a. 4 to 6 hours a day for 6 months b. During waking hours for 2 to 3 months after the injury c. Continuously d. At night while sleeping for a year after the injury

c Elastic pressure garments are worn continuously (i.e., 24 hours a day).

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? a. Autografts b. Heterografts c. Homografts d. Xenografts

c 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 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? a. Hypernatremia b. Hypokalemia c. Hyperkalemia d. Hypercalcemia

c 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.

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? a. Albumin b. Dextrose 5% in water (D5W) c. Lactated Ringer's solution d. Normal saline solution with 20 mEq of potassium per 1,000 ml

c Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

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

c 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.

A client is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the client's arm? a. Superficial partial thickness b. Deep partial thickness c. Full partial thickness d. Full thickness

d A full-thickness burn involves total destruction of the epidermis and dermis and, in some cases, underlying tissue as well. Wound color ranges widely from white to red, brown, or black. The burned area is painless because the nerve fibers are destroyed. The wound can appear leathery; hair follicles and sweat glands are destroyed. Edema may also be present. Superficial partial-thickness burns involve the epidermis and possibly a portion of the dermis; the client will experience pain that is soothed by cooling. Deep partial-thickness burns involve the epidermis, upper dermis, and portion of the deeper dermis; the client will complain of pain and sensitivity to cold air. Full partial thickness is not a depth of burn.

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%

d 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.

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 a. increased metabolic rate. b. increased glucose demands. c. increased skeletal muscle breakdown. d. decreased catabolism.

d 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.

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

d 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 nurse is performing a home visit to a client who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following? a. Assess the client for signs of electrolyte imbalances. b. Administer fluids as prescribed. c. Assess the risk for injury recurrence. d. Assess the client's psychosocial state.

d Recovery from burns can be psychologically challenging; the nurse's assessments must address this reality. Fluid and electrolyte imbalances are infrequent during the rehabilitation phase of recovery. Burns are not typically a health problem that tends to recur; the experience of being burned tends to foster vigilance.

An emergency department nurse has just admitted a client with a burn. What characteristic of the burn will primarily determine whether the client experiences a systemic response to this injury? a. The length of time since the burn b. The location of burned skin surfaces c. The source of the burn d. The total body surface area (TBSA) affected by the burn

d Systemic effects are a result of several variables. However, TBSA and wound severity are considered the major factors that affect the presence or absence of systemic effects.

While performing a client's ordered wound care for the treatment of a burn, the client has made a series of sarcastic remarks to the nurse and criticized her technique. How should the nurse best interpret this client's behavior? a. The client may be experiencing an adverse drug reaction that is affecting his cognition and behavior. b. The client may be experiencing neurologic or psychiatric complications of his injuries. c. The client may be experiencing inconsistencies in the care that he is being provided. d. The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.

d The client may experience feelings of anger. The anger may be directed outward toward those who escaped unharmed or toward those who are now providing care. While drug reactions, complications, and frustrating inconsistencies in care cannot be automatically ruled out, it is not uncommon for anger to be directed at caregivers.

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: a. fluid resuscitation. b. infection. c. body image. d. pain management.

d 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.