Med-Surg II: Final Exam: Burns and Emergency Nursing

primary survey focuses on

-Airway -Breathing -Circulation -Disability - Exposure

Fluid resuscitation for burns:

1st 24H: 2 large bore IVs, lactated ringers 2nd 24H: colloids used to replace intravascular volume after 48-72H: Dextrose 5% if indicated, assess electrolytes

expected urine output for burn patients after fluid resuscitation

30-50 mL/H

Which area is MOST important for the nurse to assess for fluid balance in a client with full-thickness burns of the anterior trunk and thigh when monitoring fluid balance during the first 2-3 days after the burn? A. UOP every hour B. weight every day C. BP Q15 min D. extent of peripheral edema Q4H

A. UOP every hour

Which response would the nurse give to a client with third-degree burns who asks, "why do I need a temporary pigskin graft?" A. "it helps debride necrotic tissue" B. "it promotes rapid healing of the wound" C. "When sutured in place, it provides better adherence D. "topical lotions can be used concurrently with the graft"

B. "it promotes rapid healing of the wound"

A client, admitted with full thickness burns two weeks ago, has lost an average of 1 lb of weight each day. Which dietary adjustment would the nurse recommend? A. increase low-sodium milk intake B. provide high-protein drinks C. Increase foods low in potassium D. Provide 10% more calories in the form of fat

B. provide high-protein drinks

The nurse is caring for a patient with severe burns and determines that the client is at risk for hypovolemic shock. Which physiological finding supports the nurse's conclusion? A. decreased glomerular filtration rate B. Extensive blood clots through burned tissues C. Plasma proteins moving out of the intravascular compartment D. Sodium retention occurring as a result of the aldosterone mechanism

C. Plasma proteins moving out of the intravascular compartment

Which complication will it prevented administering a histamine H-2 antagonist to a client who has extensive burns? A. Colitis B. Gastritis C. Stress ulcer D. Metabolic acidosis

C. Stress ulcer

A client in the acute phase of burn recovery may exhibit an increase in which value? A. Serum sodium B. Hematocrit level C. Serum potassium D. Urinary output

D. Urinary output

The client has full thickness burns to40% of the body, including both legs,is being transferred from acommunity hospital to the burncenter. Which measure should beinstituted before the transfer? A. 22 gauge IV line w/ lactated ringers infusion B. Wounds covered w/ moist sterile dressings C. No IV pain medication D. ensure adequate peripheral circulation to both feet

D. ensure adequate peripheral circulation to both feet

A client has full-thickness burns to65% of the body, including the chestarea. After establishing a patentairway, which collaborativeintervention is a priority for the client? A. replace fluid and electrolytes B. prevent contractors of the extremities C. monitor urine output hourly D. prepare to assist wit escharotomy

D. prepare to assist wit escharotomy

For a client experiencing the emergent phase secondary to serious burns involving a large surface of the skin, which action is the nurse's priority during this phase? A. Alleviating pian B. preventing infection C. Replacing blood loss D. restoring fluid volume

D. restoring fluid volume

primary survey: disability

GCS and pupil test

What do we never give burn patients in the emergent phase?

IM/SQ injections

Risks with burns, watch for these

capillary leak syndrome DVT infection hypovolemic shock

Triage: black

dead

second degree burn

deep partial thickness; extend through epidermis and involve part of dermis red/cherry red, painful, blistering common nerves are intact

When evaluating fluid loss for a client with burns, which relationship between a client's burned BSA and fluid loss would the nurse consider?

directly proportional

Which type of burn should be scheduled for an EKG?

electrical

third degree burn

full thickness; burn through epidermis, dermis, and involves subcutaneous tissues. PAINLESS white skin with eschar

How do we maintain the cervical spine when assessing the posterior portion of the body?

logroll the patient

priority focus of rehabilitation phase of burns

minimize functional loss and provide psychosocial support

How are grafts used in full thickness burns?

patient's skin grafted to burn site (donor site is more painful that the graft site) remove serum accumulation from grafts imobilize and elevate graft site assess for rubor and edema

primary survey: Exposure

Remove all clothing for a complete physical assessment; Prevent hypothermia by covering patient w/blankets, using heating devices, infusing warm solutions

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, the nurse identifies tachycardia, tachypnea, and dyspnea. The nurse auscultates the client's lungs and expects to hear what type of breath sound?

Stridor

Fasciotomy

a surgical incision through the fascia to relieve tension or pressure

what is the order to put on PPE

(**GMEG**) gown, mask, eyewear, gloves

if a patient is receiving breaths from a non-rebreather bag, how many to they receive if they have a pulse?

1 breath every six seconds

expected urine output for electrical burn patients

100mL/H

parkland formula

4ml/kg of body weight 1/2 within the first 8 hours 1/4 next 8H 1/4 next 8H

Based on priority for care, which client condition would the nurse assign a red tag? A. Closed fracture B. third-degree burns over 25% of the body C. Severe abdominal pain D. Bruises and superficial lacerations

B. third-degree burns over 25% of the body

what do we avoid the first 12H after burns?

colloids (albumin)

biggest concern with circumferential burn

compartment syndrome

Phases of burn treatment: emergent: acute: rehabilitation

emergent: ends when fluid resuscitation is complete acute: begins at end of emergent and lasts until all full thickness wounds are healed rehabilitation phase: begins when patient is healed and capable of self care

In which order would the nurse take these actions when a client arrives in the ER with burns on the chest? 1. Cover the client with a warm blanket 2. Insert an IV 3. Assess client's RR 4. Calculate the extent of the client's burns

3. Assess client's RR 2. Insert an IV 1. Cover the client with a warm blanket 4. Calculate the extent of the client's burns

A client who has partial-thickness burns on the chest, abdomen, and right side arrives in the emergency department. which action will the nurse take FIRST? A. remove the client's clothing B. Evaluate weather the client has inhaled smoke C. insert IV catheter in unaffected arm D. Determine the extent of the burns using rule of 9s

B. Evaluate weather the client has inhaled smoke

Which intervention would be used as first aid for a client who has burn injuries from an electrical current until the client is transferred to a health care facility? A. Cover burns w/ ice B. Leave adherent clothing in place C. wrap client in clean, dry sheet D. remove as much burned clothing as possible E. Immerse the burned body part in cool water

B. Leave adherent clothing in place C. wrap client in clean, dry sheet D. remove as much burned clothing as possible

Which change would the nurse instruct the client to go see a PCP for when a client who sustained deep partial-thickness burns refuses to seek medical attention? A. blisters appear B. UOP decreases C. edema and redness occur D. white patches develop

B. UOP decreases

The nurse evaluates the condition of a client with upper body burns. Which assessment finding indicates potential respiratory obstruction? (Select all that apply) A. Soot on legs B. brassy cough C. deep breathing D. Singed nasal hair E. Dark mucus membranes

B. brassy cough D. Singed nasal hair E. Dark mucus membranes

Which action might have led to increased edema in the tissues surrounding chemical burns after a factory explosion? A. stabilizing cervical spine B. lowering burned limbs below the heart C. Brushing dry chemical from skin before irrigation D. flushing chemical from wound with NS

B. lowering burned limbs below the heart

primary survey: breathing

ensure O2 sat and O2 delivery

how do we feed burn patients?

enteral feedings; high protein, high calorie

Triage: blue

expected to die, nothing you can do

primary survey: circulation

feel for pulse (central), assess skin color/temp, assess cap refill; start 2 large bore IVs (14 or 16) LACTED RINGERS, aggressive fluid resuscitation

Which type of burn would the nurse suspect in a client admitted with a burn injury that has erythema and mild swelling?

first degree burn

primiroty concerns for emergent phase of burn care

fluid resuscitation

focus areas in the acute phase of burns

fluid resuscitation prevent infection metabolic support pain management wound care

Describe the difference in full-thickness and partial-thickness burns

full-thickness burns extend into the subcutaneous tissue partial-thickness burns extend through the epidermis and part of the dermis

what are burn patients at risk for in the emergent phase?

hypovolemic shock hyperkalemia hyponatremia

primary survey: Airway

jaw-thrust maneuver, protect cervical spine

Triage: red

life-threatening injury

Triage: Green

minor injury

Triage: yellow

non-life threatening injury

When is EET preferred?

patient cannot protect airway

biggest cause of death for inhalation injury

pneumonia

how do we position burn patients

position of comfort is NOT the best to prevent contractors.

escharotomy

removal of burn scar tissue

What are s/s of an inhalation injury?

respiratory distress horsiness black around nares or in throat

Which type of burns would the nurse assessing burn injuries identify on fire survivors with pink to cherry-red skin with blisters?

second degree burns

what is the process of medications for intubation?

sedate, paralize, intubate

what are the first things we do when a burn patient comes in?

tetanus shot, remove jewelry, contact lenses, and non-adherent clothing

fourth degree burns

thick and penetrating to muscle or bone

rule of nines

used to calculate body surface area

What can make burns more complicated?

age, health status, site of injury, mechanism of injury, depth of burn

Tx of inhalation injury

aggressive pulmonary toileting intubation 100% O2