Week 9 Burns Flashcards
The nurse is preparing to perform a dressing change on a patient who has multiple partial and full-thickness burn injuries to their bilateral upper arms, back, and torso. The patient reports a 7/10 on the pain scale and states they are fearful of seeing the wounds for the first time. Which outcome statement addresses the patient’s priority hypothesis?
A) The nurse will perform the dressing change during the shift
B) The nurse will support wound healing by providing proper nutrition
C) The patient will report feeling less fearful before the dressing change
D) The patient’s pain will be controlled prior to scheduled dressing changes
D) The patient’s pain will be controlled prior to scheduled dressing changes
Since the patient reports a pain score of 7/10, the nurse would create an expected outcome to address this priority first. Dressing changes can be painful for the patient, however are necessary since they prevent infection and facilitate healing. To address this, the nurse should take action to assess pain and administer pain medications, as needed, prior to dressing changes.
The charge nurse working in the burn unit is reviewing the patient assignments. Using the rules of nines, which patient has the most extensive burn?
A) A middle-aged adult who received burns to their entire bilateral lower extremities
B) An older patient with a burn to their right anterior arm from a burner on a hot stove
C) A young adult who received burns to their posterior bilateral lower legs
D) An adult patient who received burns to posterior upper back from a fire
A) A middle-aged adult who received burns to their entire bilateral lower extremities
Using the rule of nines, these burns affect bilateral anterior and posterior legs (18% + 18%), for a total of 36% of total body surface area (TBSA). This patient has the most extensive burns.
The nurse working in the emergency department is admitting a patient with multiple burns covering their arms and legs after dropping a pot of boiling water. Which clinical finding(s) support the diagnosis of second-degree superficial partial thickness burns? Select all that apply.
A. Exposure of a tendon
B. Pink burns without blisters
C. Waxy appearing skin
D. Black charred skin
E. Red, fluid-filled blisters
E. Red, fluid-filled blisters
Second-degree superficial partial-thickness burns can be red with clear blisters; wet, as if they are weeping; and are even more painful than first-degree burns. A second-degree deep partial thickness burn may vary in color from yellow or white to red; have blisters, and can be wet or dry.
A nurse is caring for a client who sustained a burn injury from exposure to steam. The nurse should expect the client’s provider to diagnose them with which type of burn?
A) Radiation
B) Electrical
C) Chemical
D) Thermal
Thermal burns are caused by scalds from hot liquids, steam, open flames, or by direct contact with hot objects.
A nurse is caring for a client with second-degree burns to their entire right upper and lower extremities. How should the nurse classify this client’s burns according to the rule of nines?
A) 27%
B) 9%
C) 18%
D) 36%
A) 27%
In adults, the severity of burns is calculated using the rule of nines. The rule of nines evaluates several distinct sections of the body’s total surface area for the presence and degree of burns. This client’s body percentage totals 27% because the entire right upper extremity is 9% of the total body surface area, and the entire right lower extremity is 18% of the total body surface area, totaling 27%.
A client who was a victim of a fire presents to the emergency department with first-degree burns on bilateral upper extremities. How should the nurse expect the client’s burns to appear? Select all that apply.
A. Blistered
B. Weeping
C. Blanchable
D. Red
E. Necrotic
F. Dry
C. Blanchable
First-degree burns involve the epidermis only. These burn injuries usually appear blanchable, meaning that compression causes the area to turn white.
D. Red
First-degree burns involve the epidermis only. These burn injuries will typically appear red.
F. Dry
First-degree burns involve the epidermis only. These burn injuries will typically appear dry.
A client arrives at the trauma center via ambulance after a motor vehicle accident in which they sustained a full-thickness burn to 36% of their total body surface area. The client has the following vital signs:
Blood pressure 71/36 mmHg
Heart rate 119 beats/min
Respiratory rate 22 beats/min
Oxygen saturation 97% on 3L nasal cannula
First responders tell the nurse caring for the client that they have initiated oxygen therapy and have established intravenous access in the right antecubital vein. Upon initial assessment, the client has burn injuries to bilateral lower extremities and pedal pulses which are weak and thready. What is the nurse’s most appropriate initial action?
A) Prepare the client for rapid sequence intubation
B) Reassess the pedal pulses with a doppler
C) Obtain a urine specimen with straight catheterization
D) Assess the patency of the intravenous catheter
D) Assess the patency of the intravenous catheter
The priority intervention for this client is to provide fluid resuscitation. The client is currently experiencing shock, and the nurse should prioritize restoration of circulating volume to augment perfusion to vital organs. Because the first responders gained intravenous access, the nurse may use this line to administer fluids but should first assess the patency of the line with a normal saline flush. The nurse should insert another intravenous catheter if the line is not patent.
A nurse is caring for two clients. One client has a first-degree burn, while another has a second-degree burn. The nurse understands that these burns are classified based on which of the following?
Depth of the burn
Location of the burn
Cause of the burn
Treatment of the burn
Depth of the burn
Burn injuries can be classified based on the degree, depending on the severity. The higher degree in a burn’s classification indicates the depth of tissue affected. Burns can be classified as either first, second, third, or fourth degree, depending on the depth of the burn.
Several fire victims presented to the emergency department for treatment. Which clients should the nurse prepare for transfer to a specialized burn center?
A) A client with a second-degree burn on the right upper extremity
B) A client with a small serous blister on the left flank
C) A client with a painless burn to the left lower extremity and perineum
D) A client with a dry, reddened burn on the anterior right thigh
C) A client with a painless burn to the left lower extremity and perineum
Hospitalization in specialized burn centers is often needed for more severe burns, like partial thickness burns that cover more than 10 percent of the total body surface area; burns in sensitive areas like the face, hands, feet, genitalia, perineum, or major joints; third or fourth-degree burns; as well as electrical and chemical burns. This client has a painless burn, indicating a possible fourth-degree, or full-thickness, burn in a sensitive area of the body and in an area that accounts for more than 10% of the total body surface area (the perineum is 1%, while the entire left lower extremity is 18%). This client requires transfer to a specialized burn center for treatment.
What is the total body surface area and degree of burn for the client that sustained burns to the anterior right leg that appears reddened and blanches easily?
10%; 2nd degree
4%; 1st degree
5%; 2nd degree
9%; 1st degree
9%; 1st degree
This answer is correct because the response 9%; 1st degree is the total body surface area or degree of burn. For the client that sustains a burn, it is important to assess the skin to determine the size and depth of burn injury. This is estimated in comparison with the total body surface area (TBSA). Burn wounds are classified based on the depth of the skin injury. The first degree burn involves damage to the epidermis. The skin will appear red and dry, with blanching assessed.
While providing care for a client that sustained a 4th degree burn, which clinical presentation is expected? Select all that apply.
A) painful blisters surrounding the wound
B) presence of blanching around wound
C) presence of intense pain at site
D) wound is blackened and depressed
E) wound extends into the muscle and bone
D) wound is blackened and depressed
E) wound extends into the muscle and bone
Burn wounds are classified based on the depth of the skin injury. The first degree burn involves damage to the epidermis. The skin will appear red and dry, with blanching assessed. The second degree burn involves injury to the epidermis and dermis and presents as a painful blistered area. The third degree burn is a full thickness burn that involves the epidermis, dermis, and subcutaneous tissue area. The skin will have a white, leathery, charred black appearance with the absence of blanching. The fourth degree burn extends from the epidermis into the muscle/bone area. The wound is blackened and depressed, and sensation is completely absent.
What is the total body surface area (TBSA) of injury for the client that sustained a burn, anterior arms and head/neck, as well as the chest and abdomen?
0,27
0,45
0,18
0,32
0,32
This answer is correct because 32%% is the total body surface area of the client’s burn. For the client that sustains a burn, it is important to assess the skin to determine the size and depth of burn injury. This is estimated in comparison with the total body surface area (TBSA). For this client each anterior arm is 4.5% (9% total), the anterior head/neck is 4.5%, the chest is 9%, and the abdomen is 9%. The total is rounded to the next whole number.
During the first 24 hours after the female client sustained a 40% total body surface area (TBSA) burn, which lab value result is expected? Select all that apply.
potassium of 4.2 mg/dL
sodium of 139 mg/dL
white blood cell of 8000 per mm3
hemoglobin of 18 g/dL
hematocrit of 54%
hemoglobin of 18 g/dL
hematocrit of 54%
Changes in laboratory test values are found in different phases of recovery after a burn is sustained. The resuscitation/emergent phase is the first phase of a burn injury. This occurs at the onset of the injury and continues through the first 48 hours after. During this phase the lab value changes will be related to the fluid shift and direct tissue damage. The potassium level (3.5-5.0 mEq/L) will be increased as a result of the disruption of the sodium-potassium pump, tissue destruction, and red blood cell hemolysis. Sodium (136-145 mEq/L) is trapped in edema fluid and lost through plasma leakage causing a decreased level. The hemoglobin (F 12-16 g/dL) and hematocrit (F 37-47%) will be elevated as a result of fluid volume loss that results in hemoconcentration.
When assessing a client with full thickness burns, the nurse expects:
- small, fluid filled blisters covering the area that has been burned.
- decreased heart rate and increased blood pressure.
- hyperactive bowel sounds with decreased digestion.
- dry, leathery, waxy-white tissue.
- dry, leathery, waxy-white tissue.
This answer is correct because full thickness burns present as dry, leathery, and possibly white, red, or dark brown with a waxy appearance.
A client is brought to the hospital with fluid-filled shiny blisters over the trunk, arms, legs, and perineum that are extremely painful. Which type of burn is the client
experiencing?
First-degree burn
Second-degree burn
Third-degree burn
Fourth-degree burn
Second-degree burn
This answer is correct because second-degree burns affect the first layer of skin and extend to the dermis and are usually red, shiny, with fluid-filled blisters, and extremely painful. Both are partial-thickness burns.
