Burns Flashcards
BURNS
B - breathing
body image
U - urine output
R - rule of nines
resuscitation of fluid
N - nutrition
S - shock
silvadene
S-SHOCK- Watch the B/P, CVP, and renal function.
Silvadene-for infection.
REMEMBER THESE PEOPLE ARE AFRAID AND NEED SUPPORT!!!!!
Burn Complication
Most common complications of burn injury are skin and joint contractures and hypertrophic scarring
Because of pain, pts will assume flexed position. It predisposes wds to contracture formation
Use of physical therapy, pressure garments, splints, etc. are used
Electric Burn Complication
Patients are at risk for *dysrhythmias or cardiac arrest, *severe metabolic acidosis, and *myoglobinuria
Myoglobin and hemoglobin from damaged RBCs travel to kidneys
*Acute tubular necrosis (ATN)
*Eventual acute kidney injury
Cold Injury
Frostbite (warm them slowly)
#1 look for pulse
Classification of Burns
Superficial partial-thickness burn
Involves epidermis
Deep partial-thickness burn
Involves dermis (Pain present)
Full-thickness burn (3rd and 4th)
Involves all skin elements, nerve endings, fat, muscle, bone – NO PAIN
Burns have been defined by degrees
(first - red,
second – blister (dermis+ epi),
third - subq, and
fourth – bones & muscles)
ABA advocates categorizing burn according to depth of skin destruction
*Partial-thickness burn
*Full-thickness burn
Rule of 9s
legs total = 36
Hands total = 18
Front (Torso + Breast) = 18
Back whole = 18
Pernieum = 1
Head total = 9
Total = 100%
Burn Injury
Location of Burn
*Circumferential burns of extremities can cause circulation problems distal to burn
*Patients may also develop compartment syndrome
Severity of burn injury is determined by location of burn wound
*Face, neck, chest → respiratory obstruction
*Hands, feet, joints, eyes → self-care
*Ears, nose, buttocks, perineum → infection
3 Phases of Burn Injury
- Emergent Phase (Resuscitative) = hypovolemia = Fluid resuscitation
- Acute Phase (wound healing phase) = Avoid Septic shock
- Rehabilitative (restorative) – to avoid contractures.
Remember Burn patients move from hypovolemia to septic shock
Concern with Burn is
METABOLIC ACIDOSIS
More concerns
Fluid & Electrolyte Shifts:
Net result of fluid shift is intravascular volume depletion
*Edema
*↓ Blood pressure
*↑ Pulse
*RBC are hemolyzed -> thrombosis -> Elevated Hct
- Hyperkalemia in burn
- Hyponatremia or Hypernatremia ????
Fluid and electrolyte shifts
Colloidal osmotic pressure decreases
More fluid shifting out of vascular space into interstitial spaces
Which is the greatest concern during the emergent phase of a burn injury?
Emergent Phase lasts 48 - 72 hours after burn
The primary concern is hypovolemic shock, as the vascular fluids move into interstitial spaces (second-spacing) and areas that normally have no fluid (third-spacing), leading to vascular volume loss. Examples of third-spacing include blisters and edema.
A patient who is admitted to a burn unit is hypovolemic. A new nurse asks an experienced nurse about the patient’s condition. Which response if made by the experienced nurse is most appropriate?
a) “Blood loss from burned tissue is the most likely cause of hypovolemia.”
b) “Third spacing of fluid into fluid-filled vesicles is usually the cause of hypovolemia.”
c) “The usual cause of hypovolemia is vaporation of fluid from denuded body surfaces.”
d) “Increased capillary permeability causes fluid shifts out of blood vessels and results in hypovolemia.”
d
Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.
The patient sustained a full-thickness burn encompassing the entire right arm. What is the best indicator an escharotomy achieved its desired effect?
A. Patient rates the pain at less than 4.
B. Blood pressure remains above 120/80 mm Hg.
C. Right fingers blanch with a 2-second refill.
D. Patient maintains full range of motion for the right arm.
C. Circulation to the extremities can be severely impaired by deep circumferential burns and subsequent edema that impairs the blood supply. An escharotomy (electrocautery incision through the full-thickness eschar) is performed to restore circulation. Normal refill is less than 2 seconds.
The nurse should expect to apply which type of ordered antiseptic to a client with a burn wound, once the area has been cleansed with sterile saline?
a. copper containing
b. silver containing
c. biguanide
d. acetic acid
b. silver sulfadiazine is a metallic type of antiseptic that is widely used on burns. The silver in the solution is toxic to bacteria, and prevents them from reproducing.
Multiple patients arrive in the emergency department from a house fire. Which patient is a priority?
A. Patient with erythremic, dry burns over the arms and a history of taking prednisone
B. Patient with moist blisters over the chest and who reports pain as 10
C. Patient with dry, black skin on one hand and a history of diabetes mellitus
D. Patient with multiple reddened skin areas on the chest and with high-pitched respiratory sounds
D. Airway injury is a priority, and stridor results from a narrowing of the airway caused by edema. A history of prednisone use or diabetes is a concern for long-term infection risk, but the airway is always first.
A client with burn injury asks the nurse what the term full thickness means. The nurse should respond that burns classified as full thickness involve tissue destruction down to which level?
a. epidermis
b. dermis
c. subcutaneous tissue
d. internal organs
c. A full thickness burn involves all skin layers, including the epidermis and dermis, and may extend into the subcutaneous tissue and fat.
A child has just been admitted to the pediatric burn unit. Currently, the child is being evaluated for burns to his chest and upper legs. He complains of thirst and asks for a drink. What is the most appropriate nursing action?
a. give a small glass of clear liquid
b. give a small glass of a full liquid
c. keep the child NPO
d. order a pediatric meal tray with extra liquids
c. Until a complete assessment and treatment plan are initiated, the child should be kept NPO. A complication of major burns is paralytic ileus, so until that has been ruled out, oral fluids should not be provided.
A child was admitted to the ED with a thermal burn to the right arm and leg. Which assessment by the nurse requires immediate action?
a. coughing and wheezing
b. bright red skin with small blister on the burn sites
c. thirst
d. singed hair
a. coughing and wheezing may indicate that the child has inhaled smoke or toxic fumes. Maintaining airway patency is the highest nursing priority in this situation.
The condition of a client with extensive third degree burns begins to deteriorate. The nurse is aware that which type of shock may occur as a result of inadequate circulating blood volume that occurs with a burn injury?
a. cardiogenic
b. distributive
c. hypovolemic
d. septic
c. burns and the resulting low circulating fluid volume can cause hypovolemic shock.
What is the best method for preventing hypovolemic shock in a client admitted with severe burns?
a. administering dopamine
b. applying medical antishock trousers
c. infusing i.v. fluids
d. infusing fresh frozen plasma
c. during the early postburn period, large amounts of plasma fluid extravasates into interstitial spaces. Restoring the fluid loss is necessary to prevent hypovolemic shock; this is best accomplished with crystalloid and colloid solutions.
A client is admitted to a burn intensive care unit with extensive full thickness burns. What should be the nurse’s initial concern?
a. fluid status
b. risk for infection
c. body image
d. level of pain
a. in early burn care, the client’s greatest need has to do with fluid resuscitation because of large volume fluid loss through the damaged skin.
A triage nurse in the ED admits a 50 year old male client with second degree burns on the anterior and posterior portions of both legs. Based on the Rule of Nines, what percentage of his body is burned? Record your answer using a whole number.
36 The anterior and posterior portions of one leg are 18%, if both legs are burned, the total is 36%.
The injury that is least likely to result in a full thickness burn is:
a. sunburn
b. scald injury
c. chemical burn
d. electrical injury
a. Sunburn
When assessing a pt with a partial thickness burn, the nurse would expect to find (select all that apply)
a. blisters
b. exposed fascia
c. exposed muscles
d. intact nerve endings
e. red, shiny, wet appearance
a, d, e
A patient is admitted to the burn center with burns over his head, neck, chest, back, and left arm and hand after an explosion and fire in his garage. On admission to the unit, you auscultate wheezes throughout the lung fields. On reassessment, you notice that the wheezes are gone and the breath sounds are greatly diminished. Which of the following actions is the most appropriate next step?
a. place the pt in high fowler’s position
b. encourage the pt to cough and auscultate the lungs again
c. document the results and continue to monitor the pt’s progress
d. anticipate the need for endotracheal intubation and notify the physician
d. Anticipate the need for endotracheal intubation, and notify the physician.
Inhalation injury results in exposure of respiratory tract to intense heat or flames with inhalation of noxious chemicals, smoke, or carbon monoxide. You should anticipate the need for intubation.
Fluid and electrolyte shifts that occur during the early emergent phase include
a. adherence of albumin to vascular walls
b. movement of potassium into the vascular space
c. sequestering of sodium and water in the interstitial fluid.
d. hemolysis of red blood cells from large volumes of rapidly administered fluid.
c. sequestering of sodium and water in the interstitial fluid.
To maintain a positive nitrogen balance in a major burn, the patient must
a. increase normal caloric intake by about 3 times
b. eat a high-protein, low-fat, high-carbohydrate diet.
c. eat at least 1500 calories per day in small, frequent meals.
d. eat rice and whole wheat for the chemical effect on nitrogen balance
b. eat a high-protein, low-fat, high-carbohydrate diet.
The patient should be encouraged to eat high-protein, high-carbohydrate foods to meet increased caloric needs. 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.
A patient has 25% TBSA burned from a car fire. His wounds have been debrided and covered with a silver-impregnated dressing. Your priority intervention for wound care is to:
a. reapply a new dressing without disturbing the wound bed
b. observe the wound for signs of infection during dressing changes
c. apply cool compresses for pain relief in between dressing changes
d. wash the wound aggressively with soap and water three times each day.
d. wash the wound aggressively with soap and water three times each day.
Infection is the most serious threat for further tissue injury and possible sepsis.
Pain management for the burn patient is most effective when
a. opoids are administered on a set schedule around the clock
b. the patient has as much control over the management of the pain as possible.
c. there is flexibility to administer opioids withing a dosage and frequency range
d. painful dressing changes are delayed until the pt’s pain is totally relieved.
b. the patient has as much control over the management of the pain as possible.
The more control the patient has in managing the pain, the more successful the chosen strategies. Active patient participation has been found to be effective for some patients in anticipating and coping with treatment-induced pain.
A therapeutic measure used to prevent hypertrophic scarring during the rehabilitative phase of burn recovery is:
a. applying pressure garments.
b. repositioning the pt every 2 hours
c. performing active ROM at least every 4 hours
d. massaging the new tissue with water based moisturizers
a. applying pressure garments.
Pressure can help keep a scar flat and reduce hypertrophic scarring. Gentle pressure can be maintained on the healed burn with custom-fitted pressure garments.
A patient has been treated for second- and third-degree burns over 30% of his body and is now ready for discharge. You provide discharge instructions related to wound care. Which statement indicates that the patient understands the instructions?
a. I can expect occasional periods of low grade fever and can take Tylenol every 4 hours
b. I must wear my jobst elastic garment all day and can only remove it when I’m going to bed.
c. I will need to take sponge baths at home to avoid exposing the wounds to unsterile bath water.
d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it.”
d. If any healed areas break open, I should cover them with a sterile dressing and then immediately report it.”
A nurse is caring for a patient with 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. Fluid resuscitation with the Parkland (Baxter) formula recommends that one half of the total fluid requirement should be administered in the first 8 hours, one quarter of total fluid requirement should be administered in the second 8 hours, and one quarter of total fluid requirement should be administered in the third 8 hours.
*Note**
The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment, the nurse would expect to find which of the following symptoms?
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.
*Note**
The nurse is planning care for a patient 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 patient’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, c, d, e.
escharotomy (a scalpel 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 patient with a burn injury
The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, the nurse should implement which of the following dietary choices?
A. Full liquids only
B. Whatever the patient 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 increases gluconeogenesis. Caloric needs are often in the 5000-kcal range. Failure to supply adequate calories and protein leads to malnutrition and delayed healing.
A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which of the following assessment findings would alert you 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, c. Reliable clues to the occurrence of inhalation injury is 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 color
When caring for a patient with an electrical burn injury, the nurse should question a health care provider’s order for
A. Mannitol 75 gm IV.
B. Urine for myoglobulin.
C. Lactated Ringer’s at 25 ml/hr.
D. Sodium bicarbonate 24 mEq every 4 hours.
c. Lactated Ringer’s at 25 ml/hr
Electrical injury puts the patient at risk for myoglobinuria, which can lead to acute renal tubular necrosis (ATN). Treatment consists of infusing lactated Ringer’s at a rate sufficient to maintain urinary output at 75 to 100 ml/hr. 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/hr is not sufficient to maintain adequate urine output in prevention and treatment of ATN.
A patient is admitted with first- and second-degree burns covering the face, neck, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, the nurse would calculate the extent of these burns as being
A. 9%.
B. 18%.
C. 22.5%.
D. 36%.
c.
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 patient 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 patient’s burns to cover approximately 22.5% of the total body surface area.
A male burn pt who was struck by lightning arrives at the emergency department with full thickness burns to the arms and chest and with a cervical collar in place. Which assessment finding is the nurse’s priority?
a. serum K+ of 5.6 mEq/L
b. Arterial blood ph of 7.35
c. Cervical spine fracture
d. hemoglobin 18g/dL
a. The pt’s potassium level puts them at risk for life threatening cardiac dysrhythmias.
A male pt suffered full thickness burns to the chest and back and the nurse notes the pressure alarm on his mechanical ventilator is sounding every 5 minutes. What is the most relevant assessment to prevent respiratory complications in this pt?
a. pH
b. PaCO2
c. Breath sounds
d. chest expansion
d. assessing the pt’s chest expansion is initially the most important because a sever burn that includes the anterior and posterior thorax can restrict chest expansion from eschar or scar tissue.
A patient is to undergo skin grafting with the use of cultured epithelial autografts full-thickness burns. The nurse explains to the patient that this treatment involves
a) Shaving a split-thickness layer of the patient’s skin to cover the burn wound.
b) Using epidermal growth factor to cultivate cadaver skin for temporary wound coverage.
c) Growing small specimens of the patient’s skin into sheets to use as permanent skin coverage.
d) Exposing animal skin to growth factors to decrease antigenicity so it can be used for permanent wound coverage.
c
Rationale: Cultured epithelial autograft (CEA) is a method of obtaining permanent skin from a person with limited available skin for harvesting. CEA is grown from biopsy specimens obtained from the patient’s own unburned skin.
During the emergent phase of burn injury, the nurse assesses for the presence of hypovolemia. In burn patients, hypovolemia occurs primarily as a result of
a. Blood loss from injured tissue.
b. Third spacing of fluid into fluid-filled vesicles.
c. Evaporation of fluid from denuded body surfaces.
d. Capillary permeability with fluid shift to the interstitium.
d
Rationale: Hypovolemic shock is caused by a massive shift of fluids out of the blood vessels as a result of increased capillary permeability. Water, sodium, and plasma proteins move into interstitial spaces and other surrounding tissue.
When monitoring initial fluid replacement for the patient with 40% TBSA deep partial-thickness and full-thickness burns, which finding is of most concern to the nurse?
a) Serum K+ of 4.5 mEq/L
b) Urine output of 35 mL/hr
c) Decreased bowel sounds
d) Blood pressure of 86/72 mm Hg
d
Rationale: Adequacy of fluid replacement is assessed by urine output and cardiac parameters. Urine output should be 0.5 to 1 mL/kg/hr. Mean arterial pressure should be >65 mm Hg, systolic BP >90 mm Hg, and heart rate <120 beats/min. A blood pressure of 86/72 indicates inadequate fluid replacement. However, the MAP is calculated at 77 mm Hg.
The client arrives at the emergency department following a burn injury that occurred in the basement at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client?
a. 100% oxygen via an aerosol mask
b. Oxygen via nasal cannula at 15L/min
c. Oxygen via nasal cannula at 10L/min
d. 100% oxygen via a tight fitting, non rebreather face mask
d. 100% oxygen via a tight fitting, non rebreather face mask
In evaluating the adequacy of fluid resuscitation, the nurse understands that which of the following would provide the most reliable indicator for determining the adequacy?
a. vital signs
b. urine output
c. mental status
d. peripheral pulses
b. urine output
The nurse is caring for a client who suffered an inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client?
a. coma
b. flushing
c. dizziness
d. tachycardia
b. flushing
signs include flushing, headache, decreased visual acuity, decreased cerebral functioning, and slight breathlessness.
*Note**
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. decreased heart rate
b. increased urinary output
c. increased blood pressure
d. elevated hematocrit levels
d. during the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shift.
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50, a pulse of 110, and urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following prescriptions?
a. transfusing 1 unit of packed red blood cells
b. administering a diuretic to increase urine output
c. increasing the amount of IV lactated Ringers solution administered per hour
d. changing the IV lactated Ringer’s solution to one that contains dextrose in water.
c. fluid management during the first 24 hours following a burn injury generally includes the infusion of LR solution. Fluid resuscitation is determined by urine output and hourly urine output should be at least 30mL/hr. The client’s urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, should expect ↑ of LR’s.
The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third degree circumferential arm burn. The nurse understands that the anticipated therapeutic outcome of the escharotomy is:
a. return of distal pulses
b. brisk bleeding from the site
c. decreasing edema formation
d. formation of granulation tissue
a. Escharotomies arepreformed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third degree burn.
The adult client was burned as a result of an explosion. The burn initially affected the client’s entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client’s clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?
a. 18%
b. 24%
c. 36%
d. 48%
c. anterior head = 4.5%, upper half of anterior torso = 9%, lower half of both arms is 9%, posterior head 4.5%, upper half of posterior torso 9%, total 36%
A female pt in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose of 485 mg/dL. What is the nurse’s priority for preventing a life threatening complication of hyperglycemia for the burn patient?
a. replace the blood lost
b. maintain a neutral pH
c. Maintain fluid balance
d. Replace serum potassium
c. this pt is most likely experiencing hyperglycemic hyperosmolar nonketotic syndrome (HHNKS) which dehydrates a patient rapidly. This increases the pt’s risk for hypovolemia and hypotension.
A pt who has an inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage?
a. gi distress
b. tachycardia
c. restlessness
d. hypokalemia
b. albuterol stimulates beta adrenergic receptors in the lungs to cause bronchodilation and is nonselective and also causes receptors in the heart to increase heart rate.
A pt in the emergent phase of burn care for thermal burns on 20% of the total body surface area is unconscious. Which assessment data is the most important for the nurse’s evaluation of the pt’s injuries?
a. condition of the oropharynx
b. percentage of TBSA affected
c. location of the pt in the fire
d. comorbidities of the pt
a. the pt is likely to have suffered a smoke inhalation injury because thermal burns are caused by flames that emit smoke and because the pt is unconscious.
The nurse plans emergent care for four male pt’s who have burns covering between 40-50% of the total body surface area. Rank these patients according to their risk for an inhalation injury beginning with the pt who has the highest risk.
a. has posterior chemical burns from an exhibit at a parking lot
b. has osteoporosis and electrical burns of the lower extremities
c. has thermal burns of the right side and is a volunteer fireman
d. has chronic bronchitis and thermal burns around the abdomen
d, c, a, b.
The nurse plans care for a male pt who suffered thermal burns to the entire posterior aspect of his body when he fell on an outdoor grill. Which pt need is likely to be the primary problem of this pt in the emergent phase?
a. maintain tissue oxygenation
b. halt progression of the burn
c. maintain intravascular volume
d. prevent invasion of pathogens
b. the first priority is halting the severity of the burn, to limit the depth of the burn and quick action must be a priority.
A victim of an industrial accident has chemical spilled on his face and body. The chemical, which has a pH of 7.51, is flushed with water by paramedics. What is the most important information for the receiving nurse to obtain about the pt from the paramedics?
a. containment of chemical
b. duration of water flushing
c. other injuries of the victim
d. specific location of accident
d. The nurse must know where the accident occurred to determine if the pt was rescued from an enclosed space. If so, the pt is at high risk for an inhalation injury because the enclosure concentrates the noxious fumes making an inhalation injury more likely.
Doubt
Six hours after a thermal burn covering 50% of a patients total body surface area (TBSA), the nurse obtains these data when assessing a patient. What is the priority information to communicate to the health care provider?
a. Blood pressure is 94/46 per arterial line.
b. Serous exudate is leaking from the burns.
c. Cardiac monitor shows a pulse rate of 104.
d. Urine output is 20 mL per hour for the past 2 hours.
d. urine output
Which of these nursing actions should be done first for a patient who has suffered a burn injury while working on an electrical power line?
a. Obtain the blood pressure.
b. Stabilize the cervical spine.
c. Assess for the contact points.
d. Check alertness and orientation.
b. stabilize the cervical spine.
The nurse should plan to begin rehabilitation efforts for the burn client
a. immediately after the burn has occurred
b. after the client’s circulatory status has been stabilized
c. after grafting of the burn has occurred
d. after the client’s pain has been eliminated
d. after the client’s pain has been eliminated
After the initial phase of the burn injury, the client’s plan of care will focus primarily on
a. helping the client maintain a positive self-concept
b. promoting hygiene
c. preventing infection
d. educating the client regarding care of the skin grafts
c. preventing infection
The nurse is conducting a focused assessment of the GI system of a client with a burn injury. The nurse should assess the client for
a. paralytic ileus
b. gastric distention
c. hiatal hernia
d. Curling’s ulcer
d. Curling’s ulcer
The stress ulcers secondary to systemic burns are known as Curling ulcers. Stress ulcers in patients with acute traumatic brain injury are known as Cushing ulcers.
A nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hours ago. Which of the following are findings common during this phase? Select all that apply
a. temperature of 97°F (36.1°C)
b. bradycardia
c. hyperkalemia
d. hyponatremia
e. decreased hematocrit
a. temperature of 97°F (36.1°C)
c. hyperkalemia
d. hyponatremia
A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client’s voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following?
a. pulmonary edema
b. bacterial pneumonia
c. inhalation injury
d. carbon monoxide poisoning
c. inhalation injury
What is one clinical manifestation the nurse would expect to find during the emergent phase in a patient with a full-thickness burn over the lower half of the body?
a. fever
b. shivering
c. severe pain
d. unconsciousness
b. shivering
**Note: Full thickness Burn
When assessing a patient’s full-thickness burn injury during the emergent phase, what would the nurse expect to find?
a. leathery, dry, hard skin
b. red, fluid-filled vesicles
c. massive edema at the injury site
d. serous exudate on a shiny, dark brown wound
a. leathery, dry, hard skin
Which characteristics accurately describe chemical burns? Select all that apply
a. metabolic asphyxiation may occur
b. metabolic acidosis occurs immediately following the burn
c. the visible skin injury often does not represent the full extent of tissue damage
d. lavaging with large amounts of water is important to stop the burning process with these injuries
e. alkaline substances that cause these burns continue to cause tissue damage even after being neutralized
d, e
A client is undergoing fluid replacement after being burned on 20% of her body 12 hours ago. The nursing assessment reveals a BP of 90/50, pulse of 110, and urine output of 20 ml/hr. The nurse reports the findings to the HCP and anticipates which prescription?
a. transfusing 1 unit of packed RBCs
b. administering a diuretic to increase urine output
c. increasing the amount of IV LR solution administered per hour
d. changing the IV LR solution to one that contains 5% dextrose in water
c. increasing the amount of IV LR solution administered per hour
A client is brought to the ED with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply
a. restrict fluids
b. assess for airway patency
c. administer oxygen as prescribed
d. place a cooling blanket on the client
e. elevate extremities if no fractures are present
a,b,e
quizlet links
https://quizlet.com/199570850/chapter-25-burns-flash-cards/
https://quizlet.com/527122583/exam-3-burns-nclex-questions-flash-cards/?funnelUUID=15453e8f-cd57-4b3f-a65c-00348e5a2cd4
Nursing Care <Emergent> LR administration.</Emergent>
- Wound care
Should be delayed until a patent airway, adequate circulation, and adequate fluid replacement have been achieved
Fluid therapy
Two large-bore IV lines for >15% TBSA
Type of fluid replacement based on size/depth of burn, age, and individual considerations
Parkland (Baxter) formula for fluid replacement = 4 mL * Body weight* TBSA
Drug Therapy
Tetanus immunization
Given routinely to all burn patients
Antimicrobial agents
Topical agents
Silver sulfadiazine (change the dressing every 6-12 hours)
Mafenide acetate wet the gauze
Analgesics and sedatives
Morphine
Hydromorphone (Dilaudid)
Haloperidol (Haldol)
Lorazepam (Ativan)
Midazolam (versed to sleep)
All of these give Paralytic ileus (IV push faster to relieve the pain)
- A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:
A. Acute kidney injury
B. Dysrhythmia
C. Iceberg effect
D. Hypernatremia
E. Bone fractures
F. Fluid volume overload
A. Acute kidney injury
B. Dysrhythmia
C. Iceberg effect
E. Bone fractures
You receive a patient who has experienced a burn on the right leg. You note the burn contains small blisters and is extremely pinkish red and shiny/moist. The patient reports severe pain. You document this burn as:
A. 1st Degree (superficial)
B. 2nd Degree (partial-thickness)
C. 3rd Degree (full-thickness)
D. 4th Degree (deep full-thickness)
The answer is B.
- Good One**
A 58 year old female patient has superficial partial-thickness burns to the anterior head and neck, front and back of the left arm, front of the right arm, posterior trunk, front and back of the right leg, and back of the left leg. Using the Rule of Nines, calculate the total body surface area percentage that is burned?
A. 63%
B. 81%
C. 72%
D. 54%
A
A 30 year old female patient has deep partial thickness burns on the front and back of the right and left leg, front of right arm, and anterior trunk. The patient weighs 63 kg. Use the Parkland Burn Formula: What is the flow rate during the FIRST 8 hours (mL/hr) based on the total you calculated?
A. 921 mL/hr
B. 938 mL/hr
C. 158 mL/hr
D. 789 mL/hr
The answer is A: 921 mL/hr….First calculate the total amount of fluid needed with the formula: Total Amount of LR = 4 mL x BSA % x pt’s weight in kg. The pt’s weight 63 kg. BSA percentage: 58.5%…Front and back of right and left leg (36%), front of right arm (4.5%), anterior trunk (18%) which equals 58.5%. ……4 x 58.5 x 63 = 14,742 mL……Remember during the FIRST 8 hours 1/2 of the solution is infused, which will be 14,742 divided by 2 = 7371 mL……Hourly Rate: 7371 divide by 8 equals 921 mL/hr
A patient has a burn on the back of the torso that is extremely red and painful but no blisters are present. When you pressed on the skin it blanches. You document this as a:
A. 1st degree (superficial) burn
B. 2nd degree (partial-thickness) burn
C. 3rd degree (full-thickness) burn
D. 4th degree (deep full-thickness) burn
The answer is A.
A patient experienced a full-thickness burn 72 hours ago. The patient’s vital signs are within normal limits and urinary output is 50 mL/hr. This is known as what phase of burn management?
A. Emergent
B. Acute
C. Rehabilitative
B
What are some patient priorities during the emergent phase of burn management? Select all that apply
A. Fluid volume
B. Respiratory status
C. Psychosocial
D. Wound closure
E. Nutrition
A, B
During the emergent phase of burn management, you would expect the following lab values:
A. Low sodium, low potassium, high glucose, low hematocrit
B. High sodium, low potassium, low glucose, high hematocrit
C. High sodium, high potassium, high glucose, low hematocrit
D. Low sodium, high potassium, high glucose, high hematocrit
The answer is D.
