Nurse Labs (Burns Test II)
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first? A. Begin intravenous fluids B. Check the pulses with a Doppler device C. Obtain a complete blood count (CBC) D. Obtain an electrocardiogram (ECG)
A.
Match the burn with the characteristics. Epidermal injury, red, mild edema, pain, and increased sensitivity to heat. Peels in 2-3 days. Heals without scar. Example: Sunburn A. Superficial B. Superficial-Partial Thickness C. Deep Partial-Thickness D. Full-Thickness
A.
Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial-thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed. Debride the wound of eschar using gauze sponges. Administer Tramadol (Tramal) 50 mg IV. Apply silver nitrate ointment. Cover the wound using a sterile gauze dressing. Obtain a sample for wound culture.
1. Administer Tramadol (Tramal) 50 mg IV. 2. Debride the wound of eschar using gauze sponges. 3. Obtain a sample for wound culture. 4. Apply silver nitrate ointment. 5. Cover the wound using a sterile gauze dressing.
On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? A. Fluid shift B. Intense pain C. Hemorrhage D. Carbon monoxide poisoning
A.
Rehabilitation is the final phase of burn care. Which of the following are the goals during this phase? Select all that apply. A. Provide emotional support. B. Prevent hypovolemic shock. C. Promote wound healing and proper nutrition. D. Fluid replacement. E. Help the client in gaining optimal physical functioning.
A, C, and E The rehabilitation phase starts after wound closure and ends upon discharge and beyond. The goals of this phase include minimizing functional loss, promoting psychosocial support, promoting wound healing, and proper nutrition.
What statement indicates the client needs further education regarding skin grafting (allografting)? A. "Because the graft is my own skin, there is no chance it won't 'take.'" B. "For the first few days after surgery, the donor sites will be painful." C. "I will have some scarring in the area when the skin is removed for grafting." D. "I am still at risk for infection after the procedure."
A.
Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury? A. "It is normal to feel depressed." B. "I will be able to go back to work immediately." C. "I will not feel anger about my situation." D. "Once I get home, things will be normal."
A.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
A.
Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? A. Changing gloves between wound care on different parts of the client's body. B. Avoiding sharing equipment such as blood pressure cuffs between clients. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
A. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.
A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area that has been burned? A. 36% B. 54% C. 45% D. 27%
A. Based on the rule of nines, the posterior trunk equals 18%, right arm equals 9%, and the left posterior leg equals 9%. Therefore, a total of 36%.
Which assessment finding assists the nurse in confirming inhalation injury? A. Brassy cough B. Decreased blood pressure C. Nausea D. Headache
A. Brassy cough and wheezing are some signs seen with inhalation injury. Damage to airway tissue causes increased mucus production, edema, denudation of epithelium, and mucosal ulceration and hemorrhage.
Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain? A. Decreased Tissue Perfusion B. Disturbed Body Image C. Risk for Disuse Syndrome D. Risk for Ineffective Breathing Pattern
A. During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Option D: Chemical burns do not cause inhalation injury
Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury? A. Allowing the client to eat whenever he or she wants. B. Beginning parenteral nutrition high in calories. C. Limiting calories to 3000 kcal/day. D. Providing a low-protein, high-fat diet.
A. Clients should request food whenever they think that they can eat, not just according to the hospital's standard meal schedule. Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. This provides the patient or SO a sense of control; enhances participation in care and may improve intake.
A client is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders? A. Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour. B. Transfusing 1 unit of packed red blood cells. C. Administering diuretic to increase urine output. D. Changing the IV lactated Ringer's solution into dextrose in water.
A. The client's urine output indicates inadequate fluid resuscitation. Hence the physician would order an increased amount of lactated Ringer's solution administered hourly. Patients with burns of more than 20% - 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent "burn shock." Urine output of 0.5 mL/kg or about 30 - 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.
The nurse is caring for a client with a burn wound on the left knee and an autograft and skin grafting was performed. Which of the following activities will be prescribed for the client post-op? A. Elevation and immobilization of the affected leg. B. Placing the affected leg in a dependent position. C. Dangling of legs. D. Bathroom privileges.
A. Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed.
Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? A. Handwashing on entering the client's room B. Encouraging the client to cough and deep breathe C. Administering the prescribed tetanus toxoid vaccine D. Changing gloves between cleansing different burn areas
A. Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations.
What intervention will the nurse implement to reduce a client's pain after a burn injury? A. Administering morphine 4 mg intravenously. B. Administering hydromorphone (Dilaudid) 4 mg intramuscularly. C. Applying ice to the burned area D. Avoiding tactile stimulation
A. Drug therapy for pain management requires opioid and nonopioid analgesics. The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect.
The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action? A. Assess level of consciousness and pupillary reactions. B. Ask the client at what time food or liquid was last consumed. C. Auscultate breath sounds over the trachea and mainstem bronchi. D. Measure abdominal girth and auscultate bowel sounds in all four quadrants.
C.
Nurse Kelsey is a nurse manager assigned to the burn unit. Which client is best to assign to an RN who has floated from the surgery unit? A. A client with infected partial-thickness back and chest burns who has a dressing scheduled. B. A client who has just been admitted with burns over 30% of the body after a warehouse fire. C. A client with full-thickness burns on both arms who needs assistance in positioning hand splints. D. A client who requires discharge teaching about nutrition and wound care after having skin grafts.
A. Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit.
Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? A. Increased urine output, decreased urine specific gravity B. Increased peripheral edema, decreased blood pressure C. Decreased peripheral pulses, slow capillary refill D. Decreased serum sodium level, increased hematocrit
A. The "fluid remobilization" phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity
Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment? A. "My facial scars should be less severe with the use of this mask." B. "The mask will help protect my skin from sun damage." C. "This treatment will help prevent infection." D. "Using this mask will prevent scars from being permanent."
A. The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming.
___________________ infusion increases plasma volume by 37% and normalizes elevated basal levels of aldosterone and plasma renin activity in burn patients.
Albumin
Match the burn with the characteristics. Epidermis and top portion of dermis, red, moist painful, with blisters. Heals in 2-3 weeks. Heals without scar. May have pigment changes. A. Superficial B. Superficial-Partial Thickness C. Deep Partial-Thickness D. Full-Thickness E. Deep-Full thickness
B.
The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What is the priority assessment data to obtain from this client on admission? A. Airway patency B. Heart rate and rhythm C. Orientation to time, place, and person D. Current range of motion in all extremities
B.
The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
B.
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action? A. Reposition the client onto the right side. B. Document the finding as the only action. C. Notify the emergency team. D. Increase the IV flow rate.
B.
What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? A. "For the first few days after surgery, the donor sites will be painful." B. "Because the graft is my own skin, there is no chance it won't 'take'." C. "I will have some scarring in the area when the skin is removed for grafting." D. "Once all grafting is completed, my risk for infection is the same as it was before I was burned."
B.
When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by auto contamination? A. Avoiding sharing equipment such as blood pressure cuffs between clients. B. Changing gloves between wound care on different parts of the client's body. C. Using the closed method of burn wound management. D. Using proper and consistent handwashing.
B. Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.
Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action? A. Administers a laxative B. Documents the finding C. Increases the IV flow rate D. Repositions the client onto the right side
B. Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.
Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank? A. Autograft B. Homograft C. Heterograft D. Xenograft
B. Homograft is a tissue graft from a donor of the same species as the recipient. Skin from organ donors can be used as a temporary covering.
Nurse Cirie is caring for a client who suffered a smoke inhalation injury. The carbon monoxide report reveals a level of 35%. Based on the level, which of the following signs should the nurse expect in the client? A. Seizure B. Confusion C. Flushing D. Coma
B. Signs and symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension, tachycardia, headache, drowsiness, confusion, nausea, and vomiting. Mental status changes such as altered level of consciousness, disorientation, and memory loss may occur. Carbon Monoxide levels 11-20% results in flushing, cherry skin. Levels of 41-60% result in seizures
A client is being discharged today after undergoing autografting. What would the nurse include in the discharge instructions? A. Refrain from using splints. B. Avoid smoking. C. Exposed the site to sunlight. D. Encourage weight-bearing exercise.
B. Smoking can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A. Seasonal asthma B. Hepatitis B 10 years ago C. Myocardial infarction 1 year ago D. Kidney stones within the last 6 month
C.
All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately? A. Serum sodium elevated to 131 mmol/L (mEq/L) B. Serum potassium 7.5 mmol/L (mEq/L) C. Arterial pH is 7.32 D. Hematocrit is 52%
B. All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death.
The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action? A. Raise the head of the bed. B. Notify the emergency team. C. Loosen the dressings on the chest. D. Document the findings as the only action.
B. Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation.
The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's initial action? A. Administer oxygen. B. Loosen the dressing. C. Notify the emergency team. D. Document the observation as the only action.
B. Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status.
Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? A. Colloids B. Crystalloids C. Fresh-frozen plasma D. Packed red blood cells
B. Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as Normal Saline and Lactated Ringer's
A medicine student arrives at the emergency unit due to a burn injury that occurred inside the laboratory and an inhalation injury is suspected. Which of the following is the appropriate oxygen therapy for the client? A. Oxygen via nasal cannula at 5 L/min. B. Oxygen via a tight-fitting, non-rebreather face mask at 100% concentration. C. Oxygen via nasal cannula at 10 L/min. D. Oxygen via Venturi mask at 30% Fi02.
B. If an inhalation injury is suspected, management includes the administration of oxygen via a tight-fitting, non-rebreather face mask at 100% concentration. This is prescribed until carboxyhemoglobin levels in the blood fall below 15%.
The burned client's family asks at what point the client will no longer be at increased risk for infection. What is the nurse's best response? A. "When fluid remobilization has started." B. "When the burn wounds are closed." C. "When IV fluids are discontinued." D. "When body weight is normal."
B. Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.
Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action? A. Notify the emergency team. B. Document the finding as the only action. C. Ask the client if anyone in her family has diabetes mellitus. D. Slow the intravenous infusion of dextrose 5% in Ringer's lactate.
B. Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.
What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury? A. Acute Pain B. Impaired Adjustment C. Deficient Diversional Activity D. Imbalanced Nutrition: Less than Body Requirements
B. Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning.
Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following clients requires the most immediate care? A. A 50-year-old who was admitted with electrical burns 24 hours ago and has a serum potassium level of 5 mEq/L. B. A 40-year-old with partial-thickness leg burns which has a temperature of 101.9°F and blood pressure of 89/42 mm Hg. C. A 30-year-old who returned from debridement surgery 3 hours ago and is complaining of pain (Pain scale of 7/10). D. A 25-year-old admitted 4 days previously with facial burns due to a house fire and has been crying since recent visitors left.
B. The client's vital signs indicate that life-threatening complications of sepsis may be developing. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Increased blood pressure B. Increased hematocrit levels C. Decreased heart rate D. Increased urine output
B. The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours following the injury. During this phase, there is an elevation of the hematocrit levels due to hemoconcentration from the large fluid shifts
A client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge? A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal
C.
Match the burn with the characteristics. Epidermis and mid-lower dermis, red with white patches, dry, "pain-less", no blisters, and moderate edema. Will have scar. May progress A. Superficial B. Superficial-Partial Thickness C. Deep Partial-Thickness D. Full-Thickness E. Deep-Full thickness
C.
The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? A. Place a towel roll under the client's neck or shoulder. B. Keep the client in a supine position without the use of pillows. C. Have the client turn the head from side to side 90 degrees every hour while awake. D. Keep the client in a semi-Fowler's position and actively raise the
C.
Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance? A. Allowing family members to change his dressings B. Discussing future surgical reconstruction C. Performing his own morning care D. Wearing the pressure dressings as ordered
C.
The nursing instructor is going over burn injuries. The instructor tells the students that the nursing care priorities for a patient with a burn injury include wound care, nutritional support, and prevention of complications such as infection. Based upon these care priorities, the instructor is most likely discussing a patient in what phase of burn care? A. Emergent Phase B. Immediate Resuscitative Phase C. Acute Phase D. Rehabilitation Phase
C. The acute or intermediate phase of burn care follows the emergent/resuscitative phase and begins 48 to 72 hours after the burn injury. During this phase, attention is directed toward continued assessment and maintenance of respiratory and circulatory status, fluid and electrolyte balance, and gastrointestinal function. Infection prevention, burn wound care that includes wound cleaning, topical antibacterial therapy, wound dressing, dressing changes, wound debridement, and wound grafting, pain management, and nutritional support are priorities at this stage and are discussed in detail in the following sections.
Which statement best exemplifies the client's understanding of rehabilitation after a full-thickness burn injury? A. "I am fully recovered when all the wounds are closed." B. "I will eventually be able to perform all my former activities." C. "My goal is to achieve the highest level of functioning that I can." D. "There is never full recovery from a major burn injury."
C. Although a return to pre-burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.
What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? A. The burn is full thickness rather than partial thickness. B. The client is unable to fully pronate and supinate the extremity. C. Capillary refill is slow in the digits and the distal pulse is absent. D. The client cannot distinguish the sensation of sharp versus dull in the extremity.
C. Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure, and preventing blood flow to the distal extremities, and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb.
The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? A. Seasonal asthma B. Hepatitis B 10 years ago C. Myocardial infarction 1 year ago D. Kidney stones within the last 6 month
C. It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.
A client is prescribed by the physician to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure? A. "It is the surgical removal of a thin layer of the client's own unburned skin." B. "A lengthwise incision is made through the burn eschar to relieve vasodilation." C. "It is performed at the bedside and without anesthesia." D. "It is the application of topical enzyme agents directly to the wound, and these agents digest necrotic collagen tissue."
C. An escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury
Nurse Rodrigo is receiving an endorsement from the burn unit. Which of the following clients should he assess first? A. A client who has just been transferred from the PACU after having an allograft. B. A client admitted 1 week ago with a superficial-thickness burn on the buttocks which has been waiting for 2 hours to receive discharge instructions. C. A client who has just arrived from the emergency department with burns on the neck and chest. D. A client with deep partial-thickness burns on both thighs who is complaining of severe and continuous pain.
C. Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention.
Which client factors should alert the nurse to potential increased complications with a burn injury? A. The client is a 26-year-old male. B. The client has had a burn injury in the past. C. The burned areas include the hands and perineum. D. The burn took place in an open field and ignited the client's clothing.
C. Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.
What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm? A. Risk for Ineffective Breathing Pattern B. Decreased Tissue Perfusion C. Risk for Disuse Syndrome D. Disturbed Body Image
C. Chemical burns do not cause inhalation injury.
Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate? A. The client is able to talk. B. The client is alert and oriented. C. The client's oxygen saturation is 97%. D. The client's chest movements are uninhibited.
C. Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range
A client sustained burns on the back. These areas appear dry, blotchy cherry red with white patches, blistering, doesn't blanch, no capillary refill, and reduced or absent sensation. This type of burn depth is classified as? A. Superficial partial-thickness burn B. Superficial dermal C. Deep partial-thickness burn D. Full-thickness burn
C. Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn't blanch, no capillary refill, and reduced or absent sensation. Generally, heals in 3-6 weeks, but scar formation results and skin grafting may be required.
At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? A. Immediately following the injury B. During the fluid shift C. During fluid remobilization D. During the late acute phase
C. Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output
In reviewing the burned client's laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis? A. The total white blood cell count is 9000/mm3. B. The lymphocytes outnumber the basophils. C. The "bands" outnumber the "segs." D. The monocyte count is 1,800/mm3.
C. Normally, the mature segmented neutrophils ("segs") are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature "band" neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client's immune system cannot keep pace with the infectious process.
The nurse is administering fluids intravenously as ordered to a client who acquired a full-thickness burn injury on the abdomen. To determine the sufficiency of fluid resuscitation, the nurse would monitor which of the following would provide the most reliable parameter for determining adequacy? A. Level of consciousness B. Peripheral pulses C. Urine output D. Vital signs
C. Of all the options, urine output is the most reliable indicator for determining the adequacy of fluid resuscitation.
The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? A. The medication will be effective more quickly than if given intramuscularly. B. It is less likely to interfere with the client's breathing and oxygenation. C. The danger of an overdose during fluid remobilization is reduced. D. The client delayed gastric emptying.
C. The most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? A. Pulse oximetry reading of 80% B. Expiratory stridor and nasal flaring C. Cherry red color to the mucous membranes D. Presence of carbonaceous particles in the sputum
C. The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a "cherry red" color of the mucous membranes in these clients.
Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately? A. Arterial pH, 7.32 B. Hematocrit, 52% C. Serum potassium,7.5 mmol/L (mEq/L) D. Serum sodium, 131 mmol/L (mEq/L)
C. The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death.
Louie, with burns over 35% of the body, complains of chilling. In promoting the client's comfort, the nurse should: A. Maintain room humidity below 40% B. Place top sheet on the client C. Limit the occurrence of drafts D. Keep room temperature at 80 degrees
C. A client with burns is very sensitive to temperature changes because heat is lost in the burn areas. Changes in location, character, intensity of pain may indicate developing complications (limb ischemia) or herald improvement and/or return of nerve function and sensation.
Nurse Faith should recognize that fluid shift in a client with burn injury results from an increase in the: A. Total volume of circulating whole blood B. Total volume of intravascular plasma C. Permeability of capillary walls D. Permeability of kidney tubules
C. In burn, the capillaries and small vessels dilate, and cell damage causes the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost.
The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response? A. "To increase urine output and prevent kidney damage." B. "To stimulate intestinal movement and prevent abdominal bloating." C. "To decrease hydrochloric acid production in the stomach and prevent ulcers." D. "To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock."
C. Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.
Match the burn with the characteristics. Total epidermis and entire dermis, hard, dry, leathery skin. Requires skin graft. May require escharotomy or fasciotomy. A. Superficial B. Superficial-Partial Thickness C. Deep Partial-Thickness D. Full-Thickness E. Deep-Full thickness
D.
The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? A. Superficial B. Partial-thickness superficial C. Partial-thickness deep D. Full thickness
D.
The nurse manager is observing a new nursing graduate caring for a burned client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique? A. Performing strict handwashing techniques. B. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and a plastic apron. C. Using sterile bed sheets and linens. D. Wearing gloves and a gown only when giving direct care to the client.
D.
Which of the following routes should the nurse expect the pain medication to be given to a client who was admitted with extensive burns? A. Oral B. Intramuscular C. Subcutaneous D. Intravenous
D.
In assessing the client's potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission? A. "Are you a smoker?" B. "When was your last chest x-ray?" C. "Have you ever had asthma or any other lung problem?" D. "In what exact place or space were you when you were burned?"
D. The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. The composition of smoke varies with each fire depending upon the materials being burned, the amount of oxygen available to the fire, and the nature of the fire. It is important to elucidate whether the exposure was to smoke, flames, and/or possible chemicals (both industrial and household). Duration of exposure, the location of exposure (such as if it was in an enclosed space), and any loss of consciousness are all important as well.
Which finding is characteristic during the emergent period after a deep full-thickness burn injury? A. Blood pressure of 170/100 mm Hg B. Foul-smelling discharge from wound C. Pain at site of injury D. Urine output of 10 mL/hr
D. During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreased. Urine output of 0.5 mL/kg or about 30 - 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.
The nurse is handling a client who sustained an electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure, the nurse should assess the affected extremity in which of the following? A. Sensation B. Color C. Distal circulation D. All of the above
D. Following fasciotomy, the nurse should assess pulses, color, sensation, and movement of the affected extremity as well as bleeding. A fasciotomy is an emergency procedure used to treat acute compartment syndrome.
During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? A. Increased wound pain 30 to 40 minutes after drug application B. Presence of small, pale pink bumps in the wound beds C. Decreased white blood cell count D. Increased serum creatinine level
D. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function.
Which of the following medications given to a 12-year-old client for the treatment of deep partial-thickness burn is the most important to double-check with another licensed nurse before administering it? A. Aloe Vera Relief Burn spray. B. Silver Sulfadiazine ointment. C. Omeprazole 20 mg slow IV push. D. Amitriptyline (Elavil) 50 mg PO.
D. Amitriptyline (Elavil) is useful in the management of neuropathic pain following burn injury and since it is an antidepressant if given with a child, utmost precaution is given. The FDA has issued a black box warning regarding the use of amitriptyline in adolescents and young adults (ages less than 24 years). It can increase the risk of suicidal ideation and behavior.
The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintains to retain maximum function of this joint? A. Hip maintained in 30-degree flexion, no knee flexion B. Hip flexed 90 degrees and knee flexed 90 degrees C. Hip, knee, and ankle all at maximum flexion D. Hip at zero flexion with leg flat
D. Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation.
When should ambulation be initiated in the client who has sustained a major burn? A. When all full-thickness areas have been closed with skin grafts B. When the client's temperature has remained normal for 24 hours C. As soon as possible after wound debridement is complete D. As soon as possible after the resolution of the fluid shift
D. Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.
What additional laboratory test should be performed on any African American client who sustains a serious burn injury? A. Total protein B. Tissue type antigens C. Prostate-specific antigen D. Hemoglobin S electrophoresis
D. Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait.
Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? A. Vitamin A B. Vitamin B C. Vitamin C D. Vitamin D
D. Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full-thickness burns. The loss of healthy skin following a burn injury can decrease epidermal vitamin D production
The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of recovery. B. Increase the temperature in the room and increase the IV infusion rate. C. Assess the client's airway and oxygen saturation. D. Notify the burn emergency team.
D. These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (>105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues.
Which finding indicates that fluid resuscitation has been successful for a client with a burn injury? A. Hematocrit = 60% B. Heart rate = 130 beats/min C. Increased peripheral edema D. Urine output = 50 mL/hr
D. The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate to more normal levels, as well as laboratory values. This phase occurs on days 1-3 and requires an accurate fluid resuscitation and thorough evaluation for other injuries and comorbid conditions.
Match the burn with the characteristics. Extends into fascia, muscles, tendon, and bone. Skin is blackened and depressed. Amputation is necessary. A. Superficial B. Superficial-Partial Thickness C. Deep Partial-Thickness D. Full-Thickness E. Deep-Full thickness
E.
Chemical burns do NOT cause ____________ injury
Inhalation
________________ nutrition may be given to a thermal burn patient as a last resort because it is invasive and can lead to infectious and metabolic complications.
Parenteral
