Burns Iggy NCLEX

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UNIT 5 IGGY STUDY GUIDE (SEPSIS)...

Teacher 22 terms PasslistPreview Ch. 28 C 46 terms bat What is the best method to prevent autocontamination for a client with burns?

• Change gloves when handling wounds on different

areas of the body.

• Ensure that the client is in isolation therapy.
• Restrict visitors.
• Watch for early signs of infection.
• Change gloves when handling wounds on different areas of the body.

Gloves should be changed when wounds on different areas of the body are handled and between handling old and new dressings. Isolation therapy methods and restricting visitors are used to prevent cross-contamination, not autocontamination. Watching for early signs of infection does not prevent contamination.Which strategy does the nurse include when teaching a college student about fire prevention in the dormitory room?

• Use space heaters to reduce electrical costs.
• Check water temperature before bathing.
• Do not smoke in bed.
• Wear sunscreen.
• Do not smoke in bed.

Smoking in bed increases the risk for fire because the person could fall asleep.Use of space heaters may increase the risk for fire, especially if they are knocked over and left unattended. Checking water temperature does not prevent fires, but it should be checked if the client has reduced sensation in the hands or feet.Sunscreen is advised to prevent sunburn.When teaching fire safety to parents at a school function, which advice does the school nurse offer about the placement of smoke and carbon monoxide detectors?

• "Every bedroom should have a separate smoke

detector."

• "Every room in the house should have a smoke

detector."

• "If you have a smoke detector, you don't need a

carbon monoxide detector."

• "The kitchen and the bedrooms are the only rooms that

need smoke detectors."

• "Every bedroom should have a separate smoke detector."

Teach all people to use home smoke detectors and carbon monoxide detectors and to ensure these are in good working order. The number of detectors needed depends on the size of the home. Recommendations are that each bedroom has a separate smoke detector, there should be at least one detector in the hallway of each story, and at least one detector is needed for the kitchen, each stairwell, and each home entrance. Carbon monoxide detectors are instrumental in picking up other types of carbon monoxide gas, such as from a defective heating unit.

The nurse is caring for a client with burns to the face.Which statement by the client requires further evaluation by the nurse?

• "I am getting used to looking at myself."
• "I don't know what I will do when people stare at me."
• "I know that I will never look the way I used to, even

after the scars heal."

• "My spouse does not stare at the scars as much now as

in the beginning."

• "I don't know what I will do when people stare at me."

The statement about not knowing what to do when people stare indicates that the client is not coping effectively; the nurse should assist the client in exploring coping techniques. Visits from friends and short public appearances before discharge may help the client begin adjusting to this problem. The statement that the client is getting used to looking at himself or herself, the realization that he or she will always look different than before, and stating that the client's spouse doesn't stare at the scars as much all indicate that the client is coping effectively.Community reintegration programs can assist the psychosocial and physical recovery of the client with serious burns.A client with burn injuries states, "I feel so helpless." Which nursing intervention is most helpful for this client?

• Encouraging participation in wound care
• Encouraging visitors
• Reassuring the client that he or she will be fine
• Telling the client that these feelings are normal
• Encouraging participation in wound care

Encouraging participation in wound care will offer the client some sense of control. Encouraging visitors may be a good distraction, but will not help the client achieve a sense of control. Reassuring the client that he or she will be fine is neither helpful nor therapeutic. Telling the client that his or her feelings are normal may be reassuring, but does not address the client's issue of feeling helpless.The nurse is caring for a client with burns. Which question does the nurse ask the client and family to assess their coping strategies?

• "Do you support each other?"
• "How do you plan to manage this situation?"
• "How have you handled similar situations before?"
• "Would you like to see a counselor?"
• "How have you handled similar situations before?"

Asking how the client and family have handled similar situations in the past assesses whether the client's and the family's coping strategies may be effective."Yes-or-no" questions such as "Do you support each other?" are not very effective in extrapolating helpful information. The client and family in this situation probably are overwhelmed and may not know how they will manage; asking them how they plan to manage the situation does not assess coping strategies. Asking the client and the family if they would like to see a counselor also does not assess their coping strategies.A client who was the sole survivor of a house fire says, "I feel so guilty. Why did I survive?" What is the best response by the nurse?

• "Do you want to pray about it?"
• "I know, and you will have to learn to adapt to a new

body image."

• "Tell me more."
• "There must be a reason."
• "Tell me more."

Asking the client to tell the nurse more encourages therapeutic grieving. Offering to pray with the client assumes that prayer is important to the client and does not allow for grieving; the nurse should never assume that the client is religious. The response, "I know, and you will have to learn to adapt to a new body image" only serves to add stress to the client's situation. The response, "There must be a reason" minimizes the grieving process by not allowing the client to express his or her concerns.Several clients have been brought to the emergency department after an office building fire. Which client is at greatest risk for inhalation injury?

• Middle-aged adult who is frantically explaining to the

nurse what happened

• Young adult who suffered burn injuries in a closed

space

• Adult with burns to the extremities
• Older adult with thick, tan-colored sputum
• Young adult who suffered burn injuries in a closed space

The client who suffered burn injuries in a closed space is at greatest risk for inhalation injury because the client breathed a greater concentration of confined smoke. Clients who experienced a fire typically have some type of respiratory distress. However, the client talking without difficulty demonstrates minimal respiratory distress. Extensive burns to the hands and face, not the extremities, would be a greater risk. Sputum would be carbonaceous, not tan, if the client had suffered inhalation injury.

A newly admitted client has deep partial-thickness burns.The nurse expects to see which clinical manifestations?

• Painful red and white wounds
• Painless, brownish yellow eschar
• Painful reddened blisters
• Painless black skin with eschar
• Painful red and white wounds

A painful red and white wound bed characterizes deep partial-thickness burns; blisters are rare. Painless, brownish yellow eschar characterizes a full-thickness burn. A painful reddened blister is seen with a superficial partial-thickness burn.Painless black skin with eschar is seen in a deep full-thickness burn.The client is a burn victim who is noted to have increasing edema and decreased urine output as a result of the inflammatory compensation response. What does the nurse do first?

• Administer a diuretic.
• Provide a fluid bolus.
• Recalculate fluid replacement based on time of

hospital arrival.

• Titrate fluid replacement.
• Titrate fluid replacement.

The intravenous fluid rate should be adjusted on the basis of urine output plus serum electrolyte values (titration of fluids). A common mistake in treatment is giving diuretics to increase urine output. Giving a diuretic will actually decrease circulating volume and cardiac output by pulling fluid from the circulating blood volume to enhance diuresis. Fluid boluses are avoided because they increase capillary pressure and worsen edema. Fluid replacement formulas are calculated from the time of injury, not from the time of arrival at the hospital.A client with burn injuries is being admitted. Which priority does the nurse anticipate within the first 24 hours?

• Range-of-motion exercises
• Emotional support
• Fluid resuscitation
• Sterile dressing changes
• Fluid resuscitation

The client will require fluid resuscitation because fluid does not stay in the vessels after a burn injury. Range-of-motion exercise is not the priority for this client.Although emotional support and sterile dressing changes are important, they are not the priority during the resuscitation phase of burn injury.The nurse is evaluating the effectiveness of fluid resuscitation for a client in the resuscitation phase of burn injury. Which finding does the nurse correlate with clinical improvement?

• Blood urea nitrogen (BUN), 36 mg/dL
• Creatinine, 2.8 mg/dL
• Urine output, 40 mL/hr
• Urine specific gravity, 1.042
• Urine output, 40 mL/hr

Fluid resuscitation is provided at the rate needed to maintain urine output at 30 to 50 mL/hr or 0.5 mL/kg/hr. A BUN of 36 mg/dL is above normal, a creatinine of 2.8 mg/dL is above normal, and a urine specific gravity of 1.042 is above normal.Which assessment is the nurse's highest priority in caring for a client in the acute phase of burn injury?

• Bowel sounds
• Muscle strength
• Signs of infection
• Urine output
• Signs of infection

The client with burn injury is at risk for infection as a result of open wounds and reduced immune function. Burn wound sepsis is a serious complication of burn injury, and infection is the leading cause of death during the acute phase of recovery. Assessing bowel sounds, assessing muscle strength, and assessing urine output are important but not the priority during the acute phase of burn injury.

A client is in the acute phase of burn injury. For which action does the nurse decide to coordinate with the registered dietitian?

• Discouraging having food brought in from the client's

favorite restaurant

• Providing more palatable choices for the client
• Helping the client lose weight
• Planning additions to the standard nutritional pattern
• Planning additions to the standard nutritional pattern

Nutritional requirements for the client with a large burn area can exceed 5000 kcal/day. In addition to a high calorie intake, the burn client requires a diet high in protein for wound healing. Consultation with the dietitian is required to help the client achieve the correct nutritional balance. It is fine for the client with a burn injury to have food brought in from the outside. The hospital kitchen can be consulted to see what other food options may be available to the client. It is not therapeutic for the client with burn injury to lose weight.Which clinical manifestation is indicative of wound healing for a client in the acute phase of burn injury?

• Pale, boggy, dry, or crusted granulation tissue
• Increasing wound drainage
• Scar tissue formation
• Sloughing of grafts
• Scar tissue formation

Indicators of wound healing include the presence of granulation, re- epithelialization, and scar tissue formation. Pale, boggy, dry, or crusted granulation tissue is indicative of infection, as are increasing wound drainage and sloughing of grafts.A client is in the resuscitation phase of burn injury. Which route does the nurse use to administer pain medication to the client?

• Intramuscular
• Intravenous
• Sublingual
• Topical
• Intravenous

During the resuscitation phase, the IV route is used for giving opioid drugs because of problems with absorption from the muscle and stomach. When these agents are given by the intramuscular or subcutaneous route, they remain in the tissue spaces and do not relieve pain. In addition, when edema is present, all doses are rapidly absorbed at once when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. The sublingual route may not be effective, and because the skin is too damaged, the topical route is not indicated for administering drugs to the client in the resuscitation phase of burn injury.To position a client's burned upper extremities appropriately, how does the nurse position the client's elbow?

• In a neutral position
• In a position of comfort
• Slightly flexed
• Slightly hyperextended
• In a neutral position

The neutral (extended) position is the correct placement of the elbow to prevent contracture development. Placing the elbow in a position of comfort is not the best placement because the client then usually wants to flex the joint, which increases the risk for contracture development. The slightly flexed position increases the risk for contracture development. The slightly hyperextended position is not indicated and can be painful.In assessing a client in the rehabilitative phase of burn therapy, which priority problem does the nurse anticipate?

• Intense pain
• Potential for inadequate oxygenation
• Reduced self-image
• Potential for infection
• Reduced self-image

In the rehabilitative phase of burn therapy, the client is discharged and his or her life is not the same. A priority problem of reduced self-image is expected. Intense pain and potential for inadequate oxygenation are relevant in the resuscitation phase of burn injury. Potential for infection is relevant in the acute phase of burn injury.