Lecture 5: Burns Flashcards
A client is admitted to the emergency department with burns sustained in a house fire. The client presents with bright red skin and altered mental status. Which intervention should the nurse perform first?
A. Administer 100% humidified oxygen
B. Initiate IV fluid resuscitation
C. Assess the depth and extent of burns
D. Perform wound care
A. Administer 100% humidified oxygen
Explanation: The client’s bright red skin and altered mental status suggest carbon monoxide poisoning, which requires immediate administration of 100% humidified oxygen to displace carbon monoxide from hemoglobin. Fluid resuscitation (B) is important but secondary to airway management. Assessing burns (C) and wound care (D) are necessary but not the priority in airway compromise.
A client with electrical burns is at risk for which immediate complication?
A. Hypothermia
B. Cardiac dysrhythmias
C. Hyperglycemia
D. Curling’s ulcer
Answer: B. Cardiac dysrhythmias
Explanation: Electrical burns can cause cardiac dysrhythmias due to the electrical current passing through the heart. Hypothermia (A) can occur in burn clients but is not the immediate concern. Hyperglycemia (C) is more common in the acute phase due to stress responses. Curling’s ulcer (D) is a late-stage complication.
A nurse is assessing a client with an inhalation injury. Which finding is most concerning?
A. Hoarseness and stridor
B. Cherry-red lips
C. Singed nasal hair
D. Carbonaceous sputum
Answer: A. Hoarseness and stridor
Explanation: Hoarseness and stridor indicate upper airway obstruction, which requires immediate intervention to secure the airway. Cherry-red lips (B) suggest carbon monoxide poisoning, which requires oxygen therapy but does not immediately compromise the airway. Singed nasal hair (C) and carbonaceous sputum (D) indicate inhalation injury but do not require immediate airway intervention
A client with a large burn injury has urine output of 20 mL/hr. Which intervention should the nurse anticipate?
A. Administering furosemide
B. Increasing IV fluids
C. Preparing for dialysis
D. Restricting fluids
Answer: B. Increasing IV fluids
Explanation: Low urine output (<30 mL/hr) suggests inadequate fluid resuscitation, requiring an increase in IV fluids. Furosemide (A) is inappropriate as the client is hypovolemic. Dialysis (C) may be needed later if acute kidney injury occurs. Restricting fluids (D) would worsen hypovolemia.
A client with a full-thickness burn reports no pain at the burn site. What is the best explanation for this finding?
A. The client is in shock
B. Nerve endings have been destroyed
C. Pain receptors are overstimulated
D. The burn is superficial
Answer: B. Nerve endings have been destroyed
Explanation: Full-thickness burns damage all layers of the skin, including nerve endings, leading to a loss of sensation. Shock (A) can alter mental status but does not cause localized numbness. Overstimulation of pain receptors (C) would cause more pain, not less. Superficial burns (D) are painful.
A client sustains a chemical burn from an alkali substance. What is the priority intervention?
A. Neutralize the burn with vinegar
B. Flush the area with copious amounts of water
C. Apply an ice pack
D. Cover with dry sterile gauze
Answer: B. Flush the area with copious amounts of water
Explanation: Alkali burns should be irrigated with large amounts of water to dilute the chemical. Neutralizing (A) can cause additional damage. Ice packs (C) are not recommended, as they can worsen tissue injury. Covering the wound (D) is necessary but secondary to irrigation.
Which assessment finding indicates successful fluid resuscitation in a burn client?
A. Heart rate of 130 bpm
B. Blood pressure of 80/50 mmHg
C. Urine output of 35 mL/hr
D. Decreased level of consciousness
Answer: C. Urine output of 35 mL/hr
Explanation: Adequate fluid resuscitation is indicated by urine output ≥30 mL/hr. A heart rate of 130 bpm (A) suggests ongoing hypovolemia. Low blood pressure (B) and decreased LOC (D) indicate inadequate perfusion.
A client with circumferential burns on the leg develops absent pulses. What should the nurse anticipate?
A. Elevating the leg above heart level
B. Performing an escharotomy
C. Administering morphine
D. Applying compression bandages
Answer: B. Performing an escharotomy
Explanation: Circumferential burns can cause compartment syndrome, requiring an escharotomy to relieve pressure. Elevation (A) can worsen ischemia. Pain management (C) is necessary but does not resolve the issue. Compression (D) is contraindicated.
A nurse is educating a client with a skin graft. Which statement indicates understanding?
A. “I should expose my graft to the sun to promote healing.”
B. “I should expect my graft to look identical to my normal skin.”
C. “I should avoid excessive movement to prevent damage.”
D. “I will scrub the graft site to prevent infection.”
Answer: C. “I should avoid excessive movement to prevent damage.”
Explanation: Excessive movement can disrupt graft adherence. Sun exposure (A) can cause damage. Graft appearance (B) may differ from normal skin. Scrubbing (D) can cause trauma.
Which burn location increases the risk of infection the most?
A. Hands
B. Neck
C. Perineum
D. Face
Answer: C. Perineum
Explanation: The perineum is close to bacteria-rich areas, increasing infection risk. Hands (A), neck (B), and face (D) have other concerns but lower infection risk.
Which fluid is preferred for initial resuscitation of a burn client?
A. Normal saline
B. Ringer’s lactate
C. Dextrose 5% in water
D. Albumin
Answer: B. Ringer’s lactate
Explanation: Ringer’s lactate is preferred due to its balanced electrolytes. Normal saline (A) can cause hyperchloremic acidosis. Dextrose 5% (C) is not adequate for volume replacement. Albumin (D) is used later.
A nurse assessing a burn client notes decreased bowel sounds. Which complication should be suspected?
A. Adynamic ileus
B. Curling’s ulcer
C. Peritonitis
D. Sepsis
Answer: A. Adynamic ileus
Explanation: Burn clients are at risk for paralytic ileus due to stress and hypovolemia. Curling’s ulcer (B) is a late complication. Peritonitis (C) is unlikely without infection. Sepsis (D) presents with systemic signs.
Which intervention helps prevent contractures in burn clients?
A. Keeping joints flexed
B. Applying pressure bandages
C. Avoiding ROM exercises
D. Using soft pillows under the head
Answer: B. Applying pressure bandages
Explanation: Pressure bandages prevent hypertrophic scarring. Joints should be extended (A). ROM exercises (C) prevent stiffness. Soft pillows (D) can increase ear pressure sores.
A client with extensive burns is receiving fluid resuscitation. Which assessment finding indicates the treatment is effective?
A. The client’s blood pressure remains at 80/50 mmHg
B. The client’s urine output increases to 40 mL/hr
C. The client reports thirst and dizziness
D. The client’s extremities become cool and mottled
Answer: B. The client’s urine output increases to 40 mL/hr
Explanation: Adequate fluid resuscitation is indicated by urine output of at least 30–50 mL/hr. Low blood pressure (A) suggests ongoing hypovolemia. Thirst and dizziness (C) indicate dehydration. Cool, mottled extremities (D) suggest poor perfusion.
A firefighter is brought to the emergency department after being trapped in a burning building. Which intervention is the highest priority?
A. Assessing the extent of the burns
B. Administering 100% humidified oxygen
C. Inserting a large-bore IV catheter
D. Obtaining a chest X-ray
Answer: B. Administering 100% humidified oxygen
Explanation: Smoke inhalation injuries, especially carbon monoxide poisoning, require immediate administration of 100% oxygen. Assessing burns (A) and IV access (C) are important but secondary to airway management. A chest X-ray (D) is necessary but not the first priority.
A client with circumferential burns to the chest is experiencing increasing respiratory distress. Which intervention should the nurse anticipate?
A. Administering a bronchodilator
B. Performing an escharotomy
C. Applying oxygen via nasal cannula
D. Elevating the client’s head of bed to 90 degrees
Answer: B. Performing an escharotomy
Explanation: Circumferential burns on the chest can cause restrictive eschar formation, preventing adequate chest expansion. An escharotomy relieves pressure. Bronchodilators (A) are useful for airway constriction but do not address the burn-related restriction. Oxygen (C) is helpful but does not treat the underlying cause. Elevating the head of the bed (D) may help slightly but does not resolve the issue.
A client presents with partial-thickness burns to the hands and feet. What is the nurse’s priority intervention?
A. Applying ice packs to the burn areas
B. Keeping the hands and feet elevated
C. Performing aggressive debridement
D. Restricting range of motion to prevent pain
Answer: B. Keeping the hands and feet elevated
Explanation: Elevating the hands and feet reduces edema and maintains circulation. Ice packs (A) can worsen tissue injury. Aggressive debridement (C) is not done initially. Early range of motion (D) is encouraged to prevent contractures, not restricted.
The nurse is preparing to care for a client with extensive full-thickness burns. Which intervention is most important in the first 24 hours?
A. Administering broad-spectrum antibiotics
B. Providing aggressive nutritional support
C. Initiating fluid resuscitation
D. Performing wound debridement
Answer: C. Initiating fluid resuscitation
Explanation: The most critical intervention in the first 24 hours is fluid resuscitation to prevent hypovolemic shock. Antibiotics (A) are not given prophylactically. Nutrition (B) is important but secondary in the emergent phase. Debridement (D) is necessary but not the priority.
A client with a severe burn is at risk for paralytic ileus. Which assessment finding supports this diagnosis?
A. Increased bowel sounds
B. Reports of nausea and absent bowel sounds
C. Frequent, loose stools
D. Complaints of severe burning pain in the abdomen
Answer: B. Reports of nausea and absent bowel sounds
Explanation: Paralytic ileus results in absent bowel sounds and nausea due to slowed GI motility. Increased bowel sounds (A) suggest normal function. Loose stools (C) are not expected. Burning abdominal pain (D) is unrelated to ileus.
A nurse is teaching a client with burn injuries about preventing hypertrophic scarring. Which statement indicates effective teaching?
A. “I should avoid wearing pressure garments to allow my skin to breathe.”
B. “I need to perform range of motion exercises daily.”
C. “I will massage my healed scars to increase blood flow.”
D. “I should apply ice to my scars to reduce swelling.”
Answer: B. “I need to perform range of motion exercises daily.”
Explanation: ROM exercises prevent contractures and improve function. Pressure garments (A) are used to prevent hypertrophic scarring. Massaging scars (C) is beneficial but not the most important intervention. Ice (D) is not recommended for scar management.
A nurse is caring for a client with an electrical burn. Which finding requires immediate intervention?
A. Dark brown urine output
B. A heart rate of 100 bpm
C. Pain at the burn site
D. Blisters on the extremities
Answer: A. Dark brown urine output
Explanation: Dark brown urine suggests myoglobinuria, which can cause acute kidney injury. Immediate IV fluid administration is required. A heart rate of 100 bpm (B) is normal. Pain (C) and blisters (D) are expected findings.
A nurse is caring for a client with facial burns who suddenly develops hoarseness and difficulty swallowing. What is the nurse’s priority action?
A. Suction the client’s airway
B. Elevate the head of the bed
C. Prepare for early intubation
D. Administer intravenous steroids
Answer: C. Prepare for early intubation
Explanation: Hoarseness and swallowing difficulty indicate airway compromise due to inhalation injury, requiring early intubation. Suctioning (A) does not prevent airway obstruction. Elevating the head of the bed (B) may help but is not enough. Steroids (D) are not the primary treatment.
A nurse is caring for a client in the rehabilitative phase of burn recovery. Which intervention should be included in the plan of care?
A. Restricting movement of burned areas
B. Applying continuous wet dressings
C. Encouraging participation in self-care activities
D. Using dry gauze over all healed areas
Answer: C. Encouraging participation in self-care activities
Explanation: Encouraging self-care helps the client regain independence. Movement should not be restricted (A) to prevent contractures. Continuous wet dressings (B) are not needed in the rehabilitative phase. Dry gauze (D) is unnecessary for healed skin.
A client with extensive burns is receiving Ringer’s lactate based on the Parkland formula. What is the expected nursing intervention during the first 8 hours of treatment?
A. Administer 25% of the total calculated fluid volume
B. Administer 50% of the total calculated fluid volume
C. Administer all fluid within the first 24 hours
D. Alternate between crystalloid and colloid fluids every 4 hours
Answer: B. Administer 50% of the total calculated fluid volume
Explanation: The Parkland formula requires that 50% of the total calculated fluid volume be administered within the first 8 hours post-burn, followed by 25% over the next 8 hours, and the remaining 25% in the final 8 hours. Administering only 25% (A) would be insufficient. Giving all fluid in 24 hours without proper distribution (C) can lead to complications. Colloids (D) are generally used after 24 hours.
A nurse is assessing a client with full-thickness burns to the lower extremities. Which finding requires immediate intervention?
A. The client reports severe pain in the burned areas
B. The client’s toes appear pale and cool with sluggish capillary refill
C. The client’s skin appears leathery and charred
D. The client states, “I can’t feel anything in my legs.”
Answer: B. The client’s toes appear pale and cool with sluggish capillary refill
Explanation: Pale, cool extremities with sluggish capillary refill suggest impaired circulation due to compartment syndrome, which requires an escharotomy. Pain (A) is expected in partial-thickness burns, but full-thickness burns may not have pain due to nerve damage. Leathery skin (C) and loss of sensation (D) are expected findings with full-thickness burns.
A client with severe burns is admitted to the intensive care unit. Which intervention should the nurse include in the care plan to prevent Curling’s ulcer?
A. Administering proton pump inhibitors (PPIs)
B. Keeping the client NPO for the first 72 hours
C. Elevating the head of the bed to 90 degrees
D. Encouraging early ambulation
Answer: A. Administering proton pump inhibitors (PPIs)
Explanation: Curling’s ulcer, a stress ulcer common in burn clients, is prevented with PPIs or H2 blockers. Keeping the client NPO (B) is unnecessary and may delay healing. Elevating the head of the bed (C) helps prevent aspiration but does not prevent ulcers. Early ambulation (D) is beneficial but not directly related to ulcer prevention.
A client with burns to the face and neck is developing hoarseness and stridor. What is the nurse’s priority action?
A. Provide humidified oxygen
B. Assess for carbonaceous sputum
C. Prepare for intubation
D. Suction the airway
Answer: C. Prepare for intubation
Explanation: Hoarseness and stridor indicate impending airway obstruction from inhalation injury, requiring early intubation. Humidified oxygen (A) is helpful but will not prevent complete airway obstruction. Carbonaceous sputum (B) suggests inhalation injury but is not the priority. Suctioning (D) does not address the underlying airway swelling.
A nurse is educating a client in the rehabilitative phase of burn recovery. Which statement indicates the client understands the teaching?
A. “I will avoid using pressure garments to allow my skin to breathe.”
B. “I should limit movement in my joints to prevent pain.”
C. “I will apply sunscreen daily and wear protective clothing.”
D. “I can stop physical therapy once my wounds heal.”
Answer: C. “I will apply sunscreen daily and wear protective clothing.”
Explanation: Burned skin remains sensitive to sun exposure, and sunscreen with protective clothing prevents hyperpigmentation and damage. Pressure garments (A) help reduce hypertrophic scarring and should be worn. Movement (B) prevents contractures and should not be limited. Physical therapy (D) should continue to maintain mobility and prevent complications.
A client with circumferential burns to the right leg is receiving fluid resuscitation. Which finding suggests the client is developing compartment syndrome?
A. Increasing pain despite analgesia
B. Dark red burn eschar
C. Urine output of 50 mL/hr
D. Presence of peripheral pulses in the affected leg
Answer: A. Increasing pain despite analgesia
Explanation: Severe pain unrelieved by medication is an early sign of compartment syndrome due to increasing pressure from edema. Dark red eschar (B) is expected. Urine output of 50 mL/hr (C) is adequate, and presence of pulses (D) suggests adequate circulation.
A client with smoke inhalation injury is admitted to the burn unit. Which assessment finding is most concerning?
A. Restlessness and confusion
B. Soot around the nostrils
C. Singed facial hair
D. A productive cough with carbonaceous sputum
Answer: A. Restlessness and confusion
Explanation: Restlessness and confusion may indicate hypoxia due to carbon monoxide poisoning or airway obstruction. Soot (B), singed hair (C), and carbonaceous sputum (D) confirm inhalation injury but do not indicate immediate respiratory failure.
A client with partial-thickness burns is experiencing intense itching during the healing process. Which nursing intervention is most appropriate?
A. Applying cold compresses to the burned area
B. Encouraging the use of pressure garments
C. Administering an antihistamine as prescribed
D. Advising the client to scratch the area gently
Answer: C. Administering an antihistamine as prescribed
Explanation: Itching is common in burn healing, and antihistamines provide relief. Cold compresses (A) are not effective for burn-related itching. Pressure garments (B) help prevent scarring but do not relieve itching. Scratching (D) can cause skin breakdown and should be avoided.
A nurse is preparing to change the dressing of a client with a burn wound. Which intervention is most important to prevent infection?
A. Applying a thick layer of antibiotic ointment
B. Performing hand hygiene before and after wound care
C. Using non-adherent dressings over the wound
D. Encouraging the client to increase protein intake
Answer: B. Performing hand hygiene before and after wound care
Explanation: Hand hygiene is the most effective way to prevent infection. Antibiotic ointments (A) are beneficial but do not replace hygiene. Non-adherent dressings (C) help with comfort but do not prevent infection. Protein intake (D) supports healing but does not directly prevent infection.
A client with a burn injury is in the acute phase of care. Which intervention best supports wound healing?
A. Limiting protein intake to prevent kidney strain
B. Increasing caloric intake with high-protein foods
C. Keeping the wound covered with dry sterile gauze
D. Encouraging complete bed rest to conserve energy
Answer: B. Increasing caloric intake with high-protein foods
Explanation: Burn clients have increased metabolic demands, and high-protein intake supports wound healing. Limiting protein (A) is not appropriate unless kidney failure is present. Dry sterile gauze (C) does not directly enhance healing. Complete bed rest (D) increases risk of complications such as contractures.
A client with severe burns is in the emergent phase of burn management. Which assessment finding requires immediate intervention?
A. Heart rate of 118 bpm
B. Blood pressure of 88/50 mmHg
C. Urine output of 35 mL/hr
D. Complaints of thirst
Answer: B. Blood pressure of 88/50 mmHg
Explanation: A low blood pressure suggests hypovolemic shock, a life-threatening complication in the emergent phase. A heart rate of 118 bpm (A) is slightly elevated but expected in response to stress. Urine output of 35 mL/hr (C) is adequate. Complaints of thirst (D) are expected but not an emergency.
A nurse is caring for a client with deep partial-thickness burns on both legs. Which nursing intervention will best prevent contractures?
A. Keeping the client on strict bed rest
B. Applying wet-to-dry dressings
C. Performing range-of-motion exercises regularly
D. Keeping the legs in a flexed position
Answer: C. Performing range-of-motion exercises regularly
Explanation: ROM exercises help prevent contractures by maintaining mobility and flexibility. Strict bed rest (A) increases contracture risk. Wet-to-dry dressings (B) are used for wound debridement but do not prevent contractures. Keeping the legs flexed (D) encourages contracture formation.
A client with a full-thickness burn is scheduled for an autograft. What is the nurse’s priority concern postoperatively?
A. Pain management
B. Prevention of infection
C. Fluid balance
D. Adequate nutrition
Answer: B. Prevention of infection
Explanation: Infection is the primary concern post-skin grafting as it can lead to graft failure. Pain management (A) is important but not the highest priority. Fluid balance (C) is critical in the emergent phase, but infection prevention becomes key postoperatively. Nutrition (D) supports healing but is secondary to infection control.
A firefighter is admitted with burns and suspected carbon monoxide poisoning. Which assessment finding is most concerning?
A. Cherry-red skin
B. Soot in the nostrils
C. Reports of headache and dizziness
D. Oxygen saturation of 98% on room air
Answer: D. Oxygen saturation of 98% on room air
Explanation: Pulse oximetry cannot differentiate between oxyhemoglobin and carboxyhemoglobin, giving a falsely normal reading despite oxygen deprivation. Cherry-red skin (A) and headache/dizziness (C) are classic signs of carbon monoxide poisoning. Soot in the nostrils (B) suggests inhalation injury but does not indicate severity.
A client with extensive burns has a sudden drop in urine output. What is the nurse’s best action?
A. Increase the IV fluid rate
B. Check for signs of compartment syndrome
C. Lower the client’s legs below heart level
D. Encourage oral fluid intake
Answer: A. Increase the IV fluid rate
Explanation: A sudden drop in urine output suggests inadequate perfusion, requiring increased IV fluids. Compartment syndrome (B) affects circulation to extremities, not kidney perfusion. Lowering the legs (C) does not improve kidney function. Oral fluids (D) are insufficient in severe burn cases requiring IV resuscitation.
A nurse is providing discharge teaching to a client recovering from a burn injury. Which statement indicates the need for further teaching?
A. “I should apply sunscreen before going outside.”
B. “I will wear my pressure garments for 23 hours a day.”
C. “I should soak my healing wounds in warm water daily.”
D. “I will continue to perform stretching exercises daily.”
Answer: C. “I should soak my healing wounds in warm water daily.”
Explanation: Soaking wounds can lead to maceration and increase infection risk. Sunscreen (A) prevents hyperpigmentation. Pressure garments (B) help reduce hypertrophic scarring. Stretching (D) prevents contractures.
A client with circumferential burns to the arm is at risk for developing which complication?
A. Airway obstruction
B. Compartment syndrome
C. Pulmonary edema
D. Myoglobinuria
Answer: B. Compartment syndrome
Explanation: Circumferential burns can cause swelling that restricts blood flow, leading to compartment syndrome. Airway obstruction (A) is more common in facial burns. Pulmonary edema (C) is associated with inhalation injury. Myoglobinuria (D) occurs in electrical burns.
A nurse is planning care for a client in the rehabilitative phase of a burn injury. Which intervention is most appropriate?
A. Keeping affected joints immobilized
B. Applying thick layers of ointment to scars
C. Encouraging independence in self-care
D. Limiting protein intake to reduce metabolic demand
Answer: C. Encouraging independence in self-care
Explanation: Promoting independence helps the client adjust to long-term recovery. Joints should be mobilized (A), not immobilized, to prevent contractures. Ointment (B) should be applied thinly to prevent occlusion. Protein (D) should be increased for wound healing.
A client with smoke inhalation injury is being monitored for respiratory distress. Which finding is most concerning?
A. Mild wheezing on auscultation
B. Frequent dry coughing
C. Progressive hoarseness
D. Sputum production
Answer: C. Progressive hoarseness
Explanation: Hoarseness can indicate impending airway obstruction due to edema. Mild wheezing (A) and coughing (B) are expected but not immediately life-threatening. Sputum production (D) is a normal response to airway irritation.
A client with burns has been prescribed a high-calorie, high-protein diet. Which meal selection indicates appropriate understanding of dietary needs?
A. Grilled chicken, mashed potatoes, and steamed broccoli
B. Vegetable soup with crackers and a side salad
C. Toast with butter and a fruit smoothie
D. White rice with sautéed vegetables
Answer: A. Grilled chicken, mashed potatoes, and steamed broccoli
Explanation: High-protein and high-calorie foods support wound healing and metabolic demands. Vegetable soup with crackers (B) is low in protein. Toast and fruit smoothie (C) lack sufficient protein. White rice and vegetables (D) are inadequate in protein and calories.
A nurse is assessing a client with burns over 35% of their total body surface area. Which finding suggests the client is entering the acute phase of burn management?
A. Increased urine output and decreasing edema
B. Low blood pressure and rapid heart rate
C. Pale, cool extremities with weak pulses
D. Increased thirst and dry mucous membranes
Answer: A. Increased urine output and decreasing edema
Explanation: The acute phase begins when fluid begins shifting back into the vascular space, resulting in increased urine output and reduced edema. Low BP and tachycardia (B) indicate continued hypovolemia. Pale, cool extremities (C) suggest poor circulation. Increased thirst (D) is common in burns but does not indicate a phase transition.
A client with full-thickness burns to the chest is having difficulty breathing due to restrictive eschar. Which intervention should the nurse anticipate?
A. Administration of IV corticosteroids
B. Performing an escharotomy
C. Placing the client in high Fowler’s position
D. Encouraging incentive spirometry
Answer: B. Performing an escharotomy
Explanation: Eschar restricts chest expansion, requiring an escharotomy to relieve pressure. IV corticosteroids (A) do not directly address the issue. High Fowler’s (C) improves oxygenation but does not relieve chest restriction. Incentive spirometry (D) is beneficial but not the immediate intervention.
A client with electrical burns is admitted. Which assessment finding is most concerning?
A. Dark, concentrated urine
B. Mild muscle weakness
C. Increased sensation in the affected area
D. Warm, pink extremities
Answer: A. Dark, concentrated urine
Explanation: Dark urine suggests myoglobinuria, which can cause acute kidney injury. Immediate IV fluid therapy is required. Mild muscle weakness (B) is common in electrical injuries but not an emergency. Increased sensation (C) is not expected but is less concerning. Warm, pink extremities (D) suggest good circulation.
A client is admitted with burns to the face, hands, and perineum. Which nursing diagnosis takes priority?
A. Risk for infection
B. Impaired nutrition
C. Risk for impaired airway clearance
D. Impaired mobility
Answer: C. Risk for impaired airway clearance
Explanation: Burns to the face increase the risk of airway edema and obstruction, making airway management the top priority. Infection risk (A) is high but secondary to airway compromise. Nutrition (B) and mobility (D) are important but not immediate priorities.
A client with burns asks why they need a high-calorie, high-protein diet. What is the best nursing response?
A. “This diet helps reduce fluid loss from your burns.”
B. “It prevents nausea and vomiting.”
C. “Your body needs extra nutrients for wound healing.”
D. “Eating more calories will prevent weight loss.”
Answer: C. “Your body needs extra nutrients for wound healing.”
Explanation: Burn injuries cause a hypermetabolic state, requiring increased protein and calories for tissue repair. Fluid loss (A) is managed with IV fluids. Nausea prevention (B) is not the primary purpose. Weight loss prevention (D) is a secondary benefit but not the main reason.
A client in the emergent phase of a burn injury is receiving IV fluid resuscitation. Which assessment finding suggests that fluid resuscitation is adequate?
A. Blood pressure of 86/40 mmHg
B. Urine output of 40 mL/hr
C. Heart rate of 130 bpm
D. Complaints of dry mouth and thirst
Answer: B. Urine output of 40 mL/hr
Explanation: Adequate resuscitation is indicated by urine output ≥30 mL/hr. Low BP (A) and tachycardia (C) suggest ongoing hypovolemia. Thirst (D) is expected but does not indicate fluid balance.
A client with deep partial-thickness burns is prescribed silver sulfadiazine (Silvadene) cream. Which statement by the client requires further teaching?
A. “I will apply the cream using sterile gloves.”
B. “I should monitor for any signs of infection.”
C. “This cream will help prevent bacterial growth.”
D. “I should rub the cream vigorously into the wound.”
Answer: D. “I should rub the cream vigorously into the wound.”
Explanation: Silvadene should be applied gently in a thin layer; vigorous rubbing can damage healing tissue. Using sterile gloves (A), monitoring for infection (B), and understanding its antibacterial properties (C) are correct
client is in the rehabilitative phase after recovering from major burns. Which intervention is most appropriate?
A. Keeping the affected area covered at all times
B. Applying pressure garments to reduce scarring
C. Avoiding direct sunlight for one month
D. Limiting range-of-motion exercises to prevent pain
Answer: B. Applying pressure garments to reduce scarring
Explanation: Pressure garments help prevent hypertrophic scarring. Affected areas (A) do not always need to be covered. Sun protection (C) is needed for longer than one month. ROM exercises (D) should be encouraged to prevent contractures.
A client with a full-thickness burn on the leg has no pain in the burned area but reports severe pain in the surrounding tissue. What is the best explanation for this finding?
A. The client is experiencing referred pain
B. Full-thickness burns destroy nerve endings
C. The client may be developing compartment syndrome
D. The pain is due to underlying muscle injury
Answer: B. Full-thickness burns destroy nerve endings
Explanation: Full-thickness burns damage nerve endings, causing loss of sensation in the burned area, but surrounding tissues remain intact and painful. Referred pain (A) is unrelated. Compartment syndrome (C) is a concern but does not explain the lack of sensation in the burned area. Muscle injury (D) could cause pain but is not the best explanation.
A nurse is monitoring a client in the acute phase of burn management. Which finding suggests the client may be developing sepsis?
A. Heart rate of 102 bpm
B. Core temperature of 39.2°C (102.5°F)
C. Pain at the burn site
D. Urine output of 40 mL/hr
Answer: B. Core temperature of 39.2°C (102.5°F)
Explanation: A high fever suggests systemic infection, a potential sign of sepsis. Mild tachycardia (A) is expected in burns but does not confirm sepsis. Pain (C) is expected. Urine output (D) is adequate and does not indicate sepsis.
