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Section 1: Rhythm Identification

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34 terms Jo_DaniPreview lippinc 47 terms Syd 1 . There has been a fire in an apartment building.All residents have been evacuated, but many are burned. Which clients should be transported to a burn center for treatment? Select all that apply.• 1. An 8-year-old with third-degree burns over 10% of his body surface area (BSA).• 2. A 20-year-old who inhaled the smoke of the fire.• 3. A 50-year-old diabetic with first- and second degree burns on his left forearm (about 5% of his BSA).• 4. A 30-year-old with second-degree burns on the back of his left leg.• 5. A 40-year-old with second-degree burns on his right arm (about 10% of his BSA).

• . 1, 2, 3. Clients who should be transferred to a

burn center include children under age 10 or adults over age 50 with second- and third-degree burns on 10% or greater of their body surface area (BSA), clients between ages 11 and 49 with second- and third-degree burns over 20% of their BSA, clients on my age with third-degree burns on more than 5% of their BSA, clients with smoke inhalation, and clients with chronic diseases, such as diabetes and heart or kidney disease.

• . The nurse in the immediate care clinic is

assessing an 80-year-old client who lives with his son's family and has scald burns on his hands and both forearms (first- and second-degree burns on 10% of his body surface area). What should the nurse do first?• 1. Clean the wounds with warm water.• 2. Apply antibiotic cream.• 3. Refer the client to a burn center.

• Cover the burns with a sterile dressing.
• . 3. The nurse should have the client transited to a burn center. The client's age and the extent of the burns require care by a burn team

id the client meets triage criteria for referral to a burn center. Because of the age of the client and the extent of the burns, the nurse should not treat the burn. Scald burns are not at high risk for infection and do not need to be cleaned, covered, or treated with antibiotic cream at this time.

• . During the emergent (resuscitative) phase of

burn injury, which of the following indicates that the client is requiring additional volume with fluid resuscitation?• 1. Serum creatinine level of 2.5 mg/dL.• 2. Little fluctuation in daily weight.• 3. Hourly urine output of 60 mL.• 4. Serum albumin level of 3.8.

• . 1. Fluid shifting into the interstitial space

causes intravascular volume depletion and decreased perfusion to the kidneys. This would result in an increase in serum creatinine. Urine out put should be frequently monitored and adequately maintained with intravenous fluid resuscitation that would be increased when a drop in urine output occurs. Urine output should be at least 30 mL/hour.Fluid replacement is based on the Parkland or Brooke formula and also the client's response by monitoring urine output, vital signs, and CVP read ings. Daily weight is important to monitor for fluid status. Little fluctuation in weight suggests that there is no fluid retention and the intake is equal to output. Exudative loss of albumin occurs in burns causing a decrease in colloid osmotic pressure. The normal serum albumin is 3.5 to 5 gm/dL.

• . A client is admitted to the hospital after

sustaining burns to the chest, abdomen, right arm, and right leg. The shaded areas in the illustration indicate the burned areas on the client's body. Using the "rule of nines," the nurse would determine that about what percentage of the client's body surface has been burned?

• 1. 18%.

• 2. 27%.

• 3. 45%.

• 4. 64%.

• . 3. According to the rule of nines, this cli

ent has sustained burns on about 45% of the body surface. The right arm is calculated as being 9%, the right leg is 18%, and the anterior trunk is 18%, for a total of 45%.

• . A priority nursing diagnosis for a client with

burns during the emergent period would be:

• 1. Excess fluid volume.

• 2. Imbalanced nutrition: Less than body

requirements.• 3. Risk for injury (falling).• 4. Risk for infection.

• . 4. Infection is a priority problem for the

burned victim because of the loss of skin integrity and alteration in body defenses. Excess fluid or imbalanced nutrition is not a priority during the emergent period. A risk for falling is not a priority for this client because the client would be on bed rest and most likely in a critical care unit.

• . Which of the following activities should

the nurse include in the plan of care for a client with burn injuries to be carried out about one-half hour before the daily whirlpool bath and dressing change?

• Soak the dressing.
• Remove the dressing.
• Administer an analgesic.
• Slit the dressing with blunt scissors.
• . 3 . Removing dressings from severe burns

exposes sensitive nerve endings to the air, which is painful. The client should be given a prescribed analgesic about one-half hour before the dressing change to promote comfort. The other activities are done as part of the whirlpool and dressing change process and not one-half hour beforehand.

• . The client with a major burn injury receives

total parenteral nutrition (TPN). The expected out

come is to:

• Correct water and electrolyte imbalances.
• Allow the gastrointestinal tract to rest.
• Provide supplemental vitamins and minerals.
• Ensure adequate caloric and protein intake.
• Nutritional support with sufficient calo

ries and protein is extremely important for a client with severe burns because of the loss of plasma protein through injured capillaries and an increased metabolic rate. Gastric dilation and paralytic ileus commonly occur in clients with severe burns, mak ing oral fluids and foods contraindicated. Water and electrolyte imbalances can be corrected by administration of I. V. fluids with electrolyte addi tives, although TPN typically includes all necessary electrolytes. Resting the gastrointestinal tract may help prevent paralytic ileus, and TPN provides vita-

• An advantage of using biologic burn grafts

such as porcine (pigskin) grafts is that they appear

to help:

• 1. Encourage formation of tough skin.• 2. Promote the growth of epithelial tissue.• 3. Provide for permanent wound closure.• 4. Facilitate development of subcutaneous tis

• Biologic dressings such as porcine grafts

serve many purposes for a client with severe bums.They enhance the growth of epithelial tissues, minimize the overgrowth of granulation tissue, prevent loss of water and protein, decrease pain, increase mobility, and help prevent infection. They do not encourage growth of tougher skin, provide for permanent wound closure, or facilitate growth of subcutaneous tissue.

• . Which of the following factors would have

the least influence on the survival and effectiveness of a burn victim's porcine grafts?• 1. Absence of infection in the wounds.• 2. Adequate vascularization in the grafted area.• 3. Immobilization of the area being grafted.• 4. Use of analgesics as necessary for pain relief.

• Analgesic administration to keep a burn

victim comfortable is important but is unlikely to influence graft survival and effectiveness. Absence of infection, adequate vascularization, and immo bilization of the grafted area promote an effective graft.