Prep U ch. 66
A burn client is transitioning from the acute phase of the injury to the rehabilitation phase. The client tells the nurse, "I can't wait to have surgery to reconstruct my face so I look like I used to." What would be the nurse's best response?
"That's something that you and your doctor will likely talk about after your scars mature."
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%
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
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%
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
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?
Administer IV fluids
A client has been burned significantly in a workplace accident. Which conditions create the need for intensive care by specifically trained personnel?
All options are correct.
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?
Assess the client's peripheral pulses distal to the dressing
A client with a severe electrical burn injury is treated in the burn unit. Which laboratory result would cause the nurse the most concern?
BUN: 28 mg/dL
Which complication is common for victims of electrical burns?
Cardiac dysrhythmia
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?
Continuously
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?
Education about home safety
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?
Decreased blood pressure
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?
Deep partial-thickness
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.
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?
Establish a patent airway.
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?
Full thickness
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
When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?
Hoarseness of the voice
The nurse recognizes that which of the following provide clues about fluid volume status? Select all that apply.
Hourly urine output Daily weights Skin turgor
The nurse is caring for a patient 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 immediately when reviewing laboratory studies?
Hyperkalemia
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 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?
Immerse the child in a cool bath.
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?
Inform the primary care provider promptly because the graft may need to be removed.
Which of the following is the preferred IV fluid for burn resuscitation?
Lactated Ringer's (LR)
When caring for a client with burns, how often a wound dressing should be changed depends on the antimicrobial in the dressing. When Aquacel Ag topical dressing is used, how often are dressings changed?
Once a week
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
Following a burn injury, the nurse determines which area is the priority for nursing assessment?
Pulmonary system
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.
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?
Roll the client in a blanket.
Leukopenia within 48 hours is a side effect associated with which topical antibacterial agent?
Sulfadiazine, silver (Silvadene)
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
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?
The causative agent
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?
The client may be experiencing anger about his circumstances that he is deflecting toward the nurse.
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?
The total body surface area (TBSA) affected by the burn
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?
To prevent contractures
A client with a partial-thickness burn injury had Biobrane applied 2 weeks ago. The nurse notices that the Biobrane is separating from the burn wound. What is the nurse's most appropriate intervention?
Trim away the separated Biobrane.
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
What is an early sign of sepsis in the burn injured client?
Widened pulse pressure
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.
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
decreased catabolism.
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?
escharotomy
Specific potential complications are common to specific types of burns. Which burns can impair ventilation?
face, neck, chest
A client has a burn on the leg related to an engine fire. When the burn area was assessed, it was determined that the client felt no pain in the area and that it appeared charred. What depth of burn injury does the client have?
full thickness (third degree)
A client who has been burned significantly is taken by air ambulance to the burn unit. What physiologic process furthers a burn injury?
inflammatory