Chapter 46: Burns: Nursing Management

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26 terms Pius_KamekaPreview Test questions for CRRN 181 terms drew1955Preview NCLEX Style Practice Questions Bur...100 terms akrrissman84Preview ATI com 198 term h_tr The nurse is assessing a client's burn for the zones of injury. Which of the following will the nurse not assess in the client at this time?

• Zone of coagulation
• Zone of eschar
• Zone of hyperemia
• Zone of stasis
• Zone of eschar

There is no zone of eschar. The zones of injury are the zone of coagulation, the zone of stasis, and the zone of hyperemia.Which of the following will the nurse most likely assess in a client diagnosed with a second-degree burn?

• No pain and necrotic areas
• No pain and scarring
• Pain and blisters
• Pain and peeling after 2 to 5 days
• Pain and blisters

A second-degree burn is a partial-thickness burn. This type of burn is very painful, has blisters that increase in size, blanches with pressure, and may or may not require grafting. The other characteristics are for first- or third-degree burns.The nurse, caring for a client with severe burns, realizes that the client's care will progress through specific

periods of treatment EXCEPT:

• acute period.
• emergent period.
• rehabilitation period.
• stabilization period.
• stabilization period.

The three periods of treatment in the care of the seriously burned client are the emergent period, the acute period, and the rehabilitation period. There is no stabilization period of burn care.A client who has experienced a burn is in the emergent phase of treatment that usually occurs during which of the following periods?

• 24 to 48 hours
• 36 to 72 hours
• 48 to 96 hours
• 1 to 7 days
• 24 to 48 hours

The emergent period is the first 24 to 48 hours after a burn. The acute phase begins after the emergent period ends and lasts until the burn is healed. The rehabilitation period begins with wound closure and continues until the patient has reached the highest level of functioning.

A client is beginning the initial treatment of a major burn in the emergency room. Which of the following interventions would not be completed?

• Inserting an indwelling urinary catheter
• Intubatng the patient
• Giving oral medications for pain management
• Starting an intravenous solution of Ringer's lactate
• Giving oral medications for pain management

Large burns cause decreased peristalsis, and therefore nothing should be given by mouth. Clients with large burns may vomit, and attention is needed to prevent them from aspirating vomitus. Prophylactic intubation may be initiated if any heat or smoke has been inhaled. Fluid replacement and urine output are necessary for the treatment of the burn client.The formula used to calculate the volume of intravenous (IV) fluid required for fluid resuscitation of a client

receiving care in the first 24 hours after a burn is:

• 1 to 2 mL of lactated Ringer's solution × body weight ×

percent burn.

• 2 to 3 mL of lactated Ringer's solution × body weight ×

percent burn.

• 2 to 4 mL of lactated Ringer's solution × body weight ×

percent burn.

• 3 to 6 mL of lactated Ringer's solution × body weight ×

percent burn.

• 2 to 4 mL of lactated Ringer's solution x body weight x percent burn.

The formula used to calculate the volume of IV fluid required for fluid resuscitation is based on the Parkland formula. Using this formula, the client's fluid requirements for the first 24 hours after injury are estimated. For adults, the formula is 2 to 4 mL of lactated Ringer's solution × body weight (in kg) × percent burn. The other amounts of fluid are incorrect for the adult client.A client is being evaluated in the emergency department following a burn injury at home. The client has second- and third-degree burns to the right and left arms, back, and both posterior legs. Using the rule of nines, the nurse

would calculate this client's burn as being:

1. 36%.

2. 45%.

3. 54%.

4. 63%.

3. 54%.

The right and left arms are 18%, the back is 18%, and the posterior legs are 18%; this equals 54%. The other calculations are incorrect.Health care professionals are required to report suspected abuse or neglect. Which of the following is not a typical sign of abuse with a burn injury?

• Emergency management notification of a burn injury

within 1 hour of occurrence

• A burn injury accompanied by fracture and bruises
• Differing accounts of how the injury occurred with

each new interview

• Treatment sought by a non-relation
• Emergency management notification of a burn injury within 1 hour of occurrence

Notifying emergency management of a burn injury within 1 hour of occurrence is not a typical sign of abuse. The other options are typical signs of abuse.The nurse is assessing a client diagnosed with second- and third-degree burns. Which of the following assessment signs would not need to be reported by the nurse?

• Brassy cough
• Hoarseness
• Respiratory rate of 36
• Urine output of 30 mL in the first hour
• Urine output of 30 mL in the first hour

A urine output of 30 to 50 mL per hour is a sign of adequate fluid hydration. A brassy cough, hoarseness, or an increasing respiratory rate can be signs of potential airway obstruction and respiratory distress.

A nurse is managing the fluid status of a client being treated for a burn. Which of following is an indicator of adequate fluid resuscitation?

• Blood pressure 95/60 mmHg
• Pulse 115 bpm
• Patient confusion
• Urine output 30 mL/hr
• Urine output 30 mL/hr

Fluid should be titrated to ensure a urine output of 30 to 50 mL/hr. The other assessment values are not indicators of adequate fluid hydration.The nurse is initiating care for a client diagnosed with burns to the chest, back, neck, and face. For this client, which of the following nursing diagnoses would receive the highest priority?

• Disturbed body image
• Impaired skin integrity
• Ineffective airway clearance
• Risk for infection
• Ineffective airway clearance

The highest priority would be to maintain the airway with adequate oxygenation and ventilation. The other nursing diagnoses would not be the first priority.A client is scheduled to receive a skin graft from another species as part of the treatment for a burn wound. Which of the following is a graft of skin obtained from another species?

• Allograft
• Autograft
• Heterograft
• Homograft
• Heterograft

A heterograft (xenograft) is a graft of skin obtained from another species, such as a pig. An autograft is a permanent graft. A homograft, or cryopreserved cadaveric allograft, is a graft of skin obtained from a cadaver 6 to 24 hours after death that is used as a temporary graft. An allograft is a graft of skin from someone of the same species.A client is recovering from a skin graft to her right arm.Which of the following nursing interventions would not be indicated for this client?

• Assess for bleeding.
• Assess for drainage underneath the graft site.
• Encourage exercise of the right arm.
• Remove dressings slowly.
• Encourage exercise of the right arm.

Exercise of the site may cause dislodgement of the skin graft. The graft should be examined every 24 hours because drainage or blood can accumulate under the graft and cause nonadherence. Dressings should be removed slowly and carefully so that the graft is not disturbed.A client diagnosed with a major burn is being prescribed medication for pain. The nurse realizes that the drug of

choice for this client will be:

• morphine sulfate.
• acetaminophen.
• aspirin.
• meperidine.
• Morphine sulfate.

Morphine sulfate is the drug of choice for pain relief for the client experiencing a burn. Acetaminophen and aspirin are not strong enough to control the pain for this client. Meperidine is not provided as the drug of choice.To support the nutritional needs of a client recovering from a burn injury, the nurse will prepare to administer which of the following?

• High carbohydrate diet
• High fat diet
• Low protein diet
• Vitamins C and A supplements
• Vitamins C and A supplements

Vitamins C and A are provided at doses higher than recommended because of the role they play as cellular antioxidants, and they are required for collagen synthesis. A high carbohydrate diet should be avoided to prevent carbon dioxide production and hyperglycemia. Protein is needed for wound healing and should be calculated according to the client's weight. Fat intake should not exceed 30% of total daily calories.

A client has been diagnosed with a full-thickness burn injury to the hands and arms. Which of the following characteristics would the nurse expect to find? (Select all that apply.)

• Blanches with fingertip pressure
• Charred vessels visible under eschar
• Many blisters that increase in size
• Nerve endings dead
• No edema
• Very painful
• Charred vessels visible under eschar
• Nerve endings dead

A full-thickness burn is a third-degree burn. A third-degree burn exhibits charred vessels visible under eschar, and the nerve endings are dead. There is no pain, and blisters are rare and do not increase in size. There is no blanching with pressure. Edema is not present with this type of burn injury.The goals of management during the emergent period after a burn include which of the following? (Select all that apply.)

• Airway management
• Aseptic technique
• Emotional support
• Fluid replacement
• Pain management
• Rehabilitation
• Airway management
• Aseptic technique
• Emotional support
• Fluid replacement
• Pain management

The goals of management during the emergent period the first 24 to 48 hours after a burn are to secure the airway, support circulation by fluid replacement, keep the client comfortable with analgesics, prevent infection through careful wound care, maintain the body temperature, and provide emotional support.Rehabilitation of the client is not an immediate concern during the emergent period.An individual's sleeve catches on fire while cooking. He runs through the kitchen and out the back door. Which of the following interventions should the family perform?(Select all that apply.)

• Have the individual stand for easy access.
• Remove any loose debris.
• Remove clothing adhered to the burned area.
• Remove jewelry.
• Use the water hose to cool the burn.
• Cover the burned areas with a clean dry material.
• Remove any loose debris.
• Remove jewelry.
• Use the water hose to cool the burn.
• Cover the burned areas with a clean dry material.

The individual should not stand. Standing will cause the flames and smoke to engulf the facial area. The best intervention is to stop the person; wrap him in a blanket, coat, sheet, or towel; and roll him on the ground to exclude oxygen and thereby put out the fire. Any water source can be used to extinguish flames, cool the burn, or dilute the chemical area. Once all the flame is extinguished, clothing (except clothing adhered to burned skin), jewelry, and debris are carefully removed. The burned areas should be covered with a dry clean material.The nurse is determining if a client who sustained a burn should be referred to a burn unit for care. Which of the following types of burn injuries should be referred to this type of care area? (Select all that apply.)

• Burn on the face
• Burn to the genitalia
• Burn to a fractured limb
• Sunburn
• Burn caused by hot water to approximately 5 inches of

the forearm

• Burn caused by chemicals
• Burn on the face
• Burn to the genitalia
• Burn to a fractured limb
• Burn caused by chemicals

The types of burn injuries that should be referred to a burn unit for care include burns to the face and genitalia; burns to a fractured limb; and burns caused by chemicals. Sunburn and a small burn from hot water do not need to be referred to a burn unit for care.