Burns Case Study

Burns Case Study Leave the first rating Students also studied Terms in this set (32) Science MedicineEmergency Medicine Save Compound Fracture (Preschooler) 30 terms JasminDRPreview

HESI RN Case Study: Burns

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26 terms K_Copeland5Preview NU272 40 terms Oliv Which action is included when a Level I disaster is declared?All local hospitals prepare to receive casualties.Which action should the nurse implement to help these family members cope with this tragedy?Designate specific family areas that are staffed with counselors.EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first?Place a disaster tag securely on each victim.Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse identify with a red tag? (Select all that apply.) A client whose vital signs include respirations at 22 breaths/min, pulse at 120 beats/min, and blood pressure at 85/52 mmHg.A client with a pulsating femur wound.A client with full thickness burns over 50% of the body.Which triage category should the nurse assign to client? Priority 1, Color Red.The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement upon admission?Establish and maintain an open airway.The nurse should document which percentage of body surface?45%.Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes his burns?Partial thickness or second degree burns.

Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the client?The nurse administers the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours.A police officer comes to the ED nursing station and asks to speak to the client concerning the bus accident because he was sitting at the front of the bus and may have witnessed the accident.Question 10 of 32 Which action should the nurse take?Inform the officer that he must first speak to the client's parents.The police officer then asks to see client's ED medical record. Which action should the nurse take concerning this request?Allow the police officer access to the requested medical records.Burn clients who surpass 20% Total Body Surface Area (TBSA) have massive shifts of fluid and electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer?Assess the gastric aspirate for pH and blood the color of coffee grounds.Curling's ulcer is a duodenal ulcer that develops in clients who have severe body surface burns. Coffee ground vomitus, or aspirate, is a term to describe hemoglobin that is darker because it has been denatured by acid in the stomach.Gastric ulceration does not occur at a pH above 7.Fluid replacement is noted to be ideal if client produces how much output/hour?Urine is recorded as hourly output of 30 mL/kg (30 mL/2.2 lbs).A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50 mL/2.2 lbs) per hour.The client is receiving an escharotomy to treat his burn complications. Which information is accurate for the nurse provide to his parents?"The HCP will make an incision in his leg to relieve the pressure." An escharotomy is a surgical incision into the eschar to relieve the constricting effect of the burned tissue. It is appropriate for the nurse to give a client's mother accurate information.While caring for a client who has burns, which nursing intervention is essential in minimizing client's potential for infection? (Select all that apply.) -Inform the client's family members that plants and flowers are not allowed in his room.Plants and flowers are not allowed because stagnant water is a potential source of bacterial growth.-Provide visitors with isolation gowns and instruction in hand hygiene.A major responsibility of the nurse is detecting infection and protecting client from infection. This must be balanced with the need for 14-year-old client to be able to visit with family and friends.Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total immersion hydrotherapy. Which intervention should the nurse implement during his hydrotherapy? (Select all that apply.) -Active range of motion exercises of his extremities.Hydrotherapy provides an excellent opportunity for exercising the extremities, an important action to help prevent contractures.-Wash burn areas thoroughly and gently with mild soap and water.This is the procedure used during hydrotherapy to debride the client's burns.

The HCP has prescribed mafenide acetate for the client's burned areas for application to the burn wounds twice a day. Topical agents such as mafenide acetate solution that deeply penetrate tissue are used to cover the wound. To prepare the client for this treatment, which intervention should the nurse implement?Premedicate with an opioid analgesic 20 minutes prior to applying this medication.This medication causes severe burning pain for up to 20 minutes after the application. Premedicating a client with an analgesic helps reduce this pain.A burn injury such as the client's produces a profound metabolic need. The client requires sufficient nutrients for wound healing and increased metabolic demands. The client can take oral nutrients and requests an evening snack. Which snack is best for the nurse to provide?A peanut butter sandwich.The client needs a high-calorie, high-protein diet. Peanut butter is high in protein and calories. Adolescents typically enjoy finger foods, such as sandwiches.Health Promotion and Maintenance The nurse needs to complete the psychosocial component of the client assessment now since it was not a priority when the client was admitted to the burn unit from the ED.Question 19 of 32 Which action is most important for the nurse to take before the assessment?Ask the parents to leave the room before obtaining information from the client.The client is developing his sense of identity. There may be questions that the client would rather not answer with his parents in the room. Questions in the psychosocial assessment include topics such as drug use, alcohol use, and sexual activity. It is important that the nurse obtain an accurate history related to these risky behaviors, which often begin in early adolescence.According to Erikson, which statement by the client indicates that the client is achieving the tasks of his stage of growth and development?"I really hate it when my mom kisses me in front of my friends." The client will be in the hospital for at least 1 month. The multidisciplinary healthcare team discusses how to best meet his growth and development needs. Which interventions will meet the client's needs during his hospital stay? (Select all that apply.) -Allow his parents to bring in CD's and video games.Adolescents usually enjoy listening to music and playing video games. These types of activities should be good distractions for the client.-Inform the parents that a laptop computer with internet access would be good for their son's socialization needs.The client is an adolescent with need for peer contact. The computer could keep him in touch with peers and provide a distraction for him.Psychosocial Integrity The client continues to improve and is scheduled for surgery to graft the burned areas. A nurse with whom he has established a bond is helping him with his morning care. The client says, "If I tell you something, will you promise not to tell anyone?" Question 22 of 32 How should the nurse respond to client?If I'm concerned that it will affect your care, then I will have to tell someone." Which response by the nurse has the highest priority? "Have you thought about how you would kill yourself?" It is the nurse's priority to assess the seriousness of the client's statement about killing himself. The more specific the plan, the higher the chance of a suicide attempt. His remarks must be taken seriously, and he should be referred to the proper professional for help.

Reduction of Risk Potential Client continues his recovery both physically and mentally. The nurse discusses wound care and surgical debridement of the burn wounds with client and his parents.Question 24 of 32 Which intervention has the highest priority?Ensure meticulous hand washing before and after the client's care.Proper hand washing is the most important intervention to help minimize the risk of cross-contamination and the spread of bacteria.Which action should the nurse implement?Outline the drainage on the dressing and write the date and time.The amount of drainage, the date and time, and the nurse's initials should be labeled on the bandage to assist the caregivers in monitoring the client for complications.Reduction of Risk Potential The client's partial-thickness and full-thickness burns require an autograft to both of his lower extremities. The procedure is explained to the client and his parents, and informed consent is obtained from his parents. The client's father asks the nurse, "Where do they get the skin to do the graft? I know the HCP told us about it, but I still don't understand." Question 26 of 32 How should the nurse respond?"The skin will probably be taken from your son's back." An autograft is a procedure in which the skin is taken from one part of the body and grafted to another site on the same individual. Autografts are useful because they are not rejected by a client's immune system.After the autograft, the client is returned to his room. One hour after he returns to his room, he is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump.There is an order for morphine 4 mg IV push every 4 to 6 hours as needed (PRN) for break through pain.The nurse determines that the client could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) 0.4 The nurse assesses both of the client's graft sites and notes that the gauze dressing over the donor site is moist and intact. What action should the nurse implement?Document this assessment in the client's chart.This assessment finding is normal. A moist gauze dressing is applied to the donor site to maintain pressure and to stop any oozing. The nurse should document that the dressing is intact.Reduction of Risk Potential The client's graft sites are healing, and he is transferred to the burn rehabilitation unit. The nurse teaches client about the importance of wearing pressure garments for about a year after going home.Question 29 of 32 How should the nurse explain to the client the rationale for wearing these pressure garments?"The pressure stocking will help prevent scarring that could occur while the burn is healing." Pressure garments help the areas that are prone to hypertrophic scarring. The client may have to wear pressure garments for up to 1 year. This response also addresses his developmental stage because scarring represents a threat to the client's body image.