PrepU Chapter 62: Managements of Patients With Burn Injury

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%

When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?

.5

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

In a client with burns on the legs, which nursing intervention helps prevent contractures?

Applying knee splints

When is the first dressing change at the site of an autograft performed?

As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery

Which type of graft utilizes the client's own skin for wound coverage?

Autograft

Which of the following is a quick assessment technique to assess the percentage of burn injury? Choose the correct option.

Comparing the client's palm with the size of the burn wound

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 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.

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.

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 burn injury requires skin grafting?

Full-thickness

Skin grafts are necessary for which of the following burns?

Fullthickness

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

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 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.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

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.

Which of the following is the preferred IV fluid for burn resuscitation?

Lactated Ringer's (LR)

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 young child is being evaluated for area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the useof which assessment tool?

Lund and Browder method

In a client who has been burned, which medication should the nurse expect to use to prevent infection?

Mafenide (Sulfamylon)

A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat?

Moisten with sterile water only.

Which of the following is the analgesic of choice for burn pain?

Morphine sulfate

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.

A client with superficial burns on the face and deep partial-thickness burns on the neck and chest undergoing treatment is anxious to know about skin grafting. For which of the following areas can skin grafting be suggested?

Neck and chest

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

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client?

Presence of soot around nasal passages

Which instruction is the most important to give a client who has recently had a skin graft?

Protect the graft from direct sunlight.

Which of the following is a true statement regarding the purposes of skin grafts?

Reduces scarring and contractures.

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?

Related to circumferential eschar

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, 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

The nurse is providing wound care for a client with burns to the lower extremities. Which topical antibacterial agent carries a side effect of leukopenia that the nurse should monitor for within 48 hours after application?

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

Which type of burn is similar to a sunburn?

Superficial partial-thickness

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 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 0.5 mL/kg/hour.

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.

When the area of burn is irregular in shape and is scattered over multiple areas of the body, which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?

Use client's palm size

Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern?

Zone of stasis

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?

face, neck, chest

Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?

Fluid resuscitation

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?"

The nurse has completed teaching home care instructions to a patent being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching?

"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn't help."

A nurse knows to assess a patient with a burn injury for gastrointestinal complications. Which of the following is a sign that indicates the presence of a paralytic ileus?

Decreased peristalsis

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided?

Application of ice

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. Select the graft described as the following: a biologic source of skin similar to that of the client.

Allograft

Which of the following measures can be used to cool a burn?

Application of cool water

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 complications is common for victims of electrical burns?

Cardiac dysrhythmia

Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns?

Deep tissue cooling

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.

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.

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:

dislodge the autografts.