#8: burngs Flashcards
A nurse is caring for a client who has second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which of the following recommendations?
A. The total 24-hour fluid requirement should be administered in the first 8 hours.
B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
C. One third of the total 24-hour fluid requirement should be administered in the first 4 hours.
D. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.
B. One half of the total 24-hour fluid requirement should be administered in the first 8 hours.
Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first eight hours, one quarter of total fluid requirement should be administered in the second eight hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
The nurse is caring for a client with superficial partial-thickness burns of the face sustained within the last 12 hours. Which of the following symptoms should the nurse expect to find?
A. blisters
B. reddening of the skin
C. destruction of all skin layers
D. damage to sebaceous glands
B. Reddening of the skin
The clinical appearance of superficial partial-thickness burns includes erythema, blanching with pressure, and pain and minimal swelling with no vesicles or blistering during the first 24 hours.
The nurse is caring for a client with partial- and full-thickness burns to 65% of the body and is planning nutritional interventions for this client. Which of the following dietary choices should the nurse implement?
A. Full liquids only
B. Whatever the client requests
C. High-protein and low-sodium foods
D. High-calorie and high-protein foods
D. High-calorie and high-protein foods
A hypermetabolic state occurs proportional to the size of the burn area. Massive catabolism can occur and is characterized by protein breakdown and increased gluconeogenesis. Failure to supply adequate calories and protein leads to malnutrition and delayed healing. Calorie-containing nutritional supplements, protein powder, supplemental vitamins, and iron supplements can be administered to aid in increasing caloric intake.
The nurse is caring for a client with an electrical burn injury. Which of the following health care provider orders should the nurse question?
A. Mannitol 75 g IV
B. Urine for myoglobulin
C. Lactated Ringer’s at 25 mL/hour
D. Sodium bicarbonate 24 mmol every 4 hours
C. Lactated Ringer’s at 25 mL/hour
Electrical injury puts the client at risk for myoglobinuria, which can lead to acute tubular necrosis. Treatment consists of infusing lactated Ringer’s at a rate sufficient to maintain urinary output at 75–100 mL/hour. Mannitol can also be used to maintain urine output. Sodium bicarbonate may be given to alkalinize the urine. The urine would also be monitored for the presence of myoglobin. An infusion rate of 25 mL/hour is not sufficient to maintain adequate urine output in prevention and treatment of acute tubular necrosis.
The nurse is admitting a client who has first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, which of the following percentages of body area have been affected?
A. 9%
B. 18%
C. 22.5%
D. 36%
C. 22.5%
Using the rule of nines, the face and neck together encompass 4.5% of the body area; the right upper arm encompasses 9% of the body area; and the entire anterior trunk encompasses 18% of the body area. Since the client has burns on only the right side of the anterior trunk, the nurse would assess that burn as encompassing half of the 18%, or 9%. Therefore, adding the three areas together, the nurse would correctly calculate the extent of this client’s burns to cover approximately 22.5% of the total body surface area.
The nurse is planning care for a client with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which of the following interventions would the nurse expect to include in this client’s care? (Select all that apply.)
A. Escharotomy
B. Administration of diuretics
C. IV and oral pain medications
D. Daily cleansing and debridement
E. Application of topical antimicrobial agent
A. Escharotomy
C. IV and oral pain medications
D. Daily cleansing and debridement
E. Application of topical antimicrobial agent
An escharotomy (a scalpel or electrocautery incision through full-thickness eschar) is frequently required to restore circulation to compromised extremities. Daily cleansing and debridement as well as application of an antimicrobial ointment are expected interventions used to minimize infection and enhance wound healing. With full-thickness burns, myoglobin and hemoglobin released into the bloodstream can occlude renal tubules. Adequate fluid replacement is used to prevent this occlusion. Pain control is essential in the care of a client with a burn injury
The nurse is admitting a client to the emergency department who has first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert the nurse to the presence of an inhalation injury? (Select all that apply.)
A. Singed nasal hair
B. Generalized pallor
C. Painful swallowing
D. Burns on the upper extremities
E. History of being involved in a large fire
A. Singed nasal hair
B.Generalized pallor
C. Painful swallowing
E. History of being involved in a large fire
Reliable clues to the occurrence of inhalation injury are the presence of facial burns, singed nasal hair, hoarseness, painful swallowing, darkened oral and nasal membranes, carbonaceous sputum, history of being burned in an enclosed space, and “cherry red” skin colour.
