Critical Care Burns
A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation?
"An allograft is a temporary wound covering obtained from cadaver skin."
When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?
.5
When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?
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?
2,400 mL
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%
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%
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
Which of the following measures can be used to cool a burn?
Application of cool water
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.
A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?
BUN: 28 mg/dL
Which of the following is a disadvantage of surgical debridement?
Bleeding
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:
Dry and pale white.
The spouse of a victim, 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.
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?
Escharotomy
Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?
Fluid resuscitation
Bill Jenkins has suffered from a burn on his leg related to an engine fire. Burn depth is determined by assessing the color, characteristics of the skin, and sensation in the area. When the burn area was assessed, it was determined that he felt no pain in the area and that it appeared charred. What depth of burn injury would he be said to have?
Full thickness (third degree)
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
Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?
Mechanical debridement
A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?
Inflammatory
A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?
Lactated Ringer's solution
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
The nurse is caring for a patient who sustained a full-thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?
Identification by the destruction of the dermis and epidermis
A child tips a pot of boiling water onto his bare legs. The mother should:
Immerse the child's legs in cool water.
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 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?
Urine output of 20 ml/hour
Which of the following is the analgesic of choice for burn pain?
Morphine sulfate
The nurse is caring for a patient with deep partial-thickness burn injuries. Which of the following statements reflect 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
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to
decrease catabolism.
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?
Preexisting conditions
A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following?
Premedicating the patient with an analgesic prior to application
The nurse is participating in a health fair about fire safety. Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire when clothes catch fire?
Roll the patient in a blanket.
The nurse knows that which topical antibacterial agent does not penetrate eschar?
Silver nitrate 0.5%
The client is admitted with full-thickness burn to the forearm. Which is the most accurate interpretation made by the nurse?
Skin grafting will be necessary.
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?
Superficial
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 0.3 to 0.5 mL/kg/hour.
A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent need is to:
Replace lost fluids and electrolytes.
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.
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.
• The perineum • The face
Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe?
5 days
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?"
A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?
27%
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%
In a client with burns on the legs, which nursing intervention helps prevent contractures?
Applying knee splints
The nurse is providing care for a patent with a full-thickness, circumferential burn of the left lower leg. During the nurse's initial shift assessment, the patient 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. The nurse's best response based on the clinical findings is which of the following?
Contact the primary care provider and prepare for an escharotomy.
The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following?
Decreased catabolism
Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis?
Deep partial-thickness
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 wait for emergency personnel.
Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?
Hyperglycemia
Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell destruction which is:
Hyperkalemia.
Following a serious thermal burn, which complication will the nurse take action to prevent first?
Hypovolemia
Which of the following types of shock will a nurse observe in a client with extensive burns?
Hypovolemic shock
The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?
Intravenous
A client presents with blistering wounds caused by an unknown chemical agent. How should the nurse intervene?
Irrigate the wounds with water.
The nurse is caring for a patient in the burn unit. Which of the following may be an early sign of sepsis in the patient with burn injury?
Narrowing pulse pressure
Which type of debridement occurs when nonliving tissues sloughs away from uninjured tissues?
Natural
Which instruction is the most important to give a client who has recently had a skin graft?
Protect the graft from direct sunlight.
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?
Risk for Impaired Gas Exchange
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?
The client has experienced extensive full-thickness burns.
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?
The early appearance of the burn injury may change.
A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient's laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient's burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply.
• "This medication is an antibacterial." • "This medication will be applied directly to the wound." • "This medication will help my burn heal."
Which of the following is to be expected soon after a major burn? Select all that apply.
• Anxiety • Tachycardia • Hypotension
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 • Sodium deficit
