Burns Flashcards
an adult client was burned in an explosion. the burn initially affected the clients 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 clients clothes caught on fire and the client ran , causing subsequent burn injuries to 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%
Nclex q 483
C. 36%
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 which finding is the anticipated therapeutic outcome of the escharotomy ?
A. return of distal pulses
B. brisk bleeding from the site
C. decreasing edema formation
D. formation of granulation tissue
Nclex q. 484
A. return of distal pulses
a client is undergoing fluid replacement after being burned on 20% of her body 12 hrs ago. the nursing assessment reveals a blood pressure of 90/50 , a pulse of 110 and a urine output of 20ml over the past hour. the cure reports the findings to the HCP and anticipates for which prescription?
A. transfusing q unit of RBCs
B. administering a diuretic to increase urine output
C. increasing the amount if IV LR solution administered per hour
D. changing the IV LR solution to one the contains 5% dextrose in water
Nclex q.485
C. increasing the amount if IV LR solution administered per hour
a client is brought to the emergency department 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 ?
SATA
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
F. prepare to give oral pain medication as prescribed
Ncex q.486
B. assess for airway patency
C. administer oxygen as prescribed
E. elevate extremities if no fractures are present
the nurse is caring for a client who sustained superficial partial thickness burns on the anterior lower legs and anterior thorax. which finding does the nurse expect to note during the resuscitation /emergency phase of the burn injury ?
A. decreased heart rate
B. increased urinary output
C. increased blood pressure
D. elevated hematocrit levels
NCLEX q. 487
D. elevated hematocrit levels
the nurse is administering fluids IV as prescribed to a client who sustained superficial partial thickness burn injuries of the back and legs. in evaluating the adequacy of fluid resuscitation the nurse understands that which assessment would provide the most reliable indicator for determining adequacy?
A. vital signs
B. urine output
C. mental status
D. peripheral pulses
NCLEX q. 490
B. urine output
the nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. the nurse manager intervenes if the new nurse planned to implement which unsafe component of protective isolation technique
A. using sterile sheets and linen
B. performing strict hand-washing technique
C. wearing gloves and a gown only when giving direct care to the client
D. wearing protective garb, including a mask, gloves, cap, shoe cover, gowns and plastic apron
NCLEX q.491
C. wearing gloves and a gown only when giving direct care to the client
the nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. what would the nurse anticipate to be prescribed for the client ?
A. out of bed activities
B. bathroom privileges
C. immobilization of the affected leg
D. placing the affected leg in a dependent position
NCLEX q.492
C. immobilization of the affected leg
a nurse in a providers office is assessing a client who has a severe sunburn. which of the following classifications should the nurse use to document this burn ?
A. superficial thickness
B. superficial partial thickness
C. deep partial thickness
D. full thickness
A. superficial thickness
a nurse is caring for a client who has sustained burns over 35% of total body surface area. the clients voice has become hoarse , brassy cough has developed and the client is drooling. the nurse should identify these findings as indication that the client has which of the following ?
A. pulmonary edema
B. bacterial pneumonia
C. Inhalation Injury
D. carbon monoxide poisoning
C. Inhalation Injury
a nurse is assessing a client who sustained deep partial-thickness and full-thickness burns over 40% of the body 24 hr ago. which of the following findings are common during this phase?
SATA
A. Temp of 97
B. bradycardia
C. Hyperkalemia
D. hyponatremia
E. decreased HCT
A. Temp of 97
C. Hyperkalemia
D. hyponatremia
a nurse is preparing to administer fentanyl to a client who sustained deep partial -thickness and full-thickness burns over 60% of the body 24 hr ago. the nurse should plan to use which of the following routes to administer the medication ?
A. SubQ
B. Oral
C. IV
D. Transdermal
C.IV
a nurse is planning care for an adult client who sustained severe burn injuries. which of the following interventions should the nurse include in the plan of care?
SATA
A. Limit visitors in the clients room
B. encourage fresh vegetables in the diet
C. increase protein intake
D. instruct the client to consume 2,000 calorie/day
E. restrict fresh flower in the room
C. increase protein intake
E. restrict fresh flower in the room
the nurse recognizes which etiology as consistent with a thermal burn ?
A. direct current
B. scalding
C. exposure to organic compounds
D. Ionizing radiation
51.1 MSDB
B. scalding
the nurse correlated which clinical manifestation with superficial -parital thickness burns ?
A. Eschar
B. Dry, leathery appearance
C.Blisters
D. waxy appearance
MSDB q. 51.2
C.Blisters
the nurse correlates which zone of burn injury as the most susceptible to sustained injury because of insufficient fluid resuscitation?
A. Zone of stasis
B. Zone of conversion
C. Zone of hyperemia
D. Zone of coagulation
MSDB Q 51.3
A. Zone of stasis
the nurse recognizes that burns to which body areas meet the criteria for referral to a burn center because of the increased risk of functional changes ?
SATA
A. Chest
B. Perineum
C. Elbows
D. Face
E. Hands
MSDB Q 51.4
B. Perineum
C. Elbows
D. Face
E. Hands
the nurse correlates which clinical manifestation with the possibility of an inhalation injury?
SATA
A. facial burns
B. singed nasal hairs
C. soot in the sputum
D. hoarseness
E. eschar
MSDB 51.5
A. facial burns
B. singed nasal hairs
C. soot in the sputum
D. hoarseness
using the resuscitation guidelines, the nurse determines that a patient requires a total of 12L of fluid in the first 24hr post injury. how much of the total volume needs to be given within the first 8hr?
A. 4,000 Ml of LR
B. 6,000 mL of LR
C. 8,00 mL of LR
D. 10,000 mL LR
MSDB q 51.6
B. 6,000 mL of LR
when hemodynamic status is monitored in a patient with a burn injury. what amount of urine output indicates adequate fluid resuscitation ?
A. 0.5 ml/kg/hr
B. 1mL/kg/hr
C. 2 mL/kg/hr
D. 3mL/kg/hr
MSDB q 51.7
A. 0.5 ml/kg/hr
the nurse recognizes which diagnostic test as most sensitive in a patient with a suspected electrical burn Injury?
A. ABG
B. CK-MG levels
C. Echocardiogram
D. Serum Carboxyhemoglobin
MSDB 51.8
B. CK-MG levels
which intervention is the priority for the patient during the emergent phase of burn management ?
A. application of silver sulfadiazine cream
B. Use of clean , dry sheets and warm blankets
C. Initiation of wet normal saline dressings
D. maintaining the injured area open to air
MSDB q 51.9
B. Use of clean , dry sheets and warm blankets
the nurse anticipate supplementary feeding via NG tube in a patient for which reasons ? SATA
A. Hypermetabolic state
B. Multiple open wounds
C. increased heat loss
D. increased caloric needs
E. burn greater than 20% TBSA
MSDB q. 51.10
A. Hypermetabolic state
B. Multiple open wounds
D. increased caloric needs
E. burn greater than 20% TBSA
which has a BSA of 18%
A.both arms
B. Both legs
C. right arm
D.left Arm
A. both arms
what is the BSA of the genitals ?
A.1%
B.4.5%
c.9%
D. 18%
A.1 %
which body part has a BSA of 36%?
torso
what is the BSA of the entire upper half of both legs ?
A. 9%
B. 18%
C. 36%
D. 4.5%
B . 18%
what are the layers of the skin?
Epidermis
dermis
hypodermis
what burn injury is in the epidermis, pink and painful still has nerves and leaves no scarring?
Superficial
what burn injury is in the epidermis and dermis , has blisters shiny and moist and are painful?
Superficial partial thickness
which burn injury is in the epidermis , dermis and hypodermis may look black yellow red and wet. no pain/limited pain as nerves are destroyed. skin will not heal?
Full thickness
what type of burn Is superficial heat ?
ex. Liquid , steam and fire ?
thermal
what type of burn is caused by toxic substances. alkalotic or acidic. ex are bleach , gasoline, pain thinner ?
Chemical
what type of burn is caused by sunburn and cancer treatment?
Radiation
what type of burn is caused by inhaling smoke which can cause flame injury or carbon monoxide poisoning
Inhalation
what type of burn is caused when an object rubs off the skin?
ex. road rash
Friction
what type of burn is caused by skin being overexposed to cold?
Cold
what type of burn is caused by a current that passes through the body without causing damage within?
electric
what are signs of inhalation injury?
hair singed around face, neck and torso
trouble talking
soot in the nose or mouth
confusion and anxiety
what is a classic symptom of carbon monoxide poisoning?
nursing bundle book
Cherry red skin
