Critical Care Burns

Critical Care Burns Leave the first rating Students also studied Terms in this set (64) Ecpi UniversityNUR 221 Save Exam #3 (CH 62 - Mgmnt of Pts With...17 terms bj_allen_ulrich Preview MLQ Ch. 62 53 terms Katherinesetera Preview chapter 57 ~ burns* 17 terms missjulievuPreview Chapte 62 terms har A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?The early appearance of the burn injury may change.Which instruction is the most important to give a client who has recently had a skin graft?Protect the graft from direct sunlight.An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?36% The nurse is caring for a patient who sustained a major burn. What serious gastrointestinal disturbance should the nurse monitor for that frequently occurs with a major burn?Paralytic ileus A patient with a severe electrical burn injury is being treated in the burn unit. Which of the following laboratory results would cause the nurse the most concern?

BUN: 28 mg/dL

Immediately after a burn injury, electrolytes need to be evaluated for a major indicator of massive cell

destruction which is:

Hyperkalemia.A client has burns to his anterior trunk and left arm. Using the Rule of the Nines, what is the TBSA burned?27%

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?The client has experienced extensive full-thickness burns.The spouse of a victim, who was struck by lightning, asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse?Electrical burns usually follow an internal path.A 6-year-old girl was playing near her family's campfire when she fell into the fire, suffering significant burns. She was taken by air ambulance to the burn unit where you practice nursing. What physiologic process furthers her burn injury?Inflammatory The client is admitted with full-thickness burn to the forearm. Which is the most accurate interpretation made by the nurse?Skin grafting will be necessary.A nurse practitioner administers first aid to a patient with a deep partial-thickness burn on his left foot. The nurse

describes the skin involvement as the:

Epidermis and a portion of deeper dermis.When using the Palmar method to estimate the extent of a small or scattered burn injury, the palm is equal to which percentage of total body surface area (TBSA)?1 A nurse is aware that after a burn injury and respiratory difficulties have been managed, the next most urgent

need is to:

Replace lost fluids and electrolytes.A client has partial-thickness burns on both lower extremities and portions of the trunk. Which I.V. fluid does the nurse plan to administer first?Lactated Ringer's solution A patient has a burn injury that has damaged the epidermis. There are no blisters, and the skin is pink in color. This type of burn injury would be documented as which of the following?Superficial The nurse is administering an analgesic to a patient with major burns. What is the recommended route for administration for this patient?Intravenous The nurse is caring for a patient with deep partial- thickness burn injuries. Which of the following statements reflect current research regarding the utilization of nonpharmacological measures in the management of burn pain?Music therapy may provide reality orientation, distraction, and sensory stimulation.

Which type of debridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar?Mechanical debridement The nurse is caring for a patient who sustained a full- thickness burn to his arm when he was scalded with boiling water. How did the nurse determine that the patient's burns are full-thickness burns?Identification by the destruction of the dermis and epidermis A client received burns to his entire back and left arm.Using the Rule of Nines, the nurse can calculate that he has sustained burns on what percentage of his body?27?lient is brought to the emergency department with partial-thickness and full-thickness burns on the left arm, left anterior leg, and anterior trunk. Using the Rule of Nines, what is the total body surface area that has been burned?36% A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims?"Are the burns associated with chemicals used in the plant?" A patient will be receiving biologic dressings. The nurse understands that biologic dressings, which use skin from living or recently deceased humans, are known by what name?Homografts A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns.Which of the following assessments would indicate the success of the fluid resuscitation?The client's urinary output is 0.3 to 0.5 mL/kg/hour.Which of the following types of shock will a nurse observe in a client with extensive burns?Hypovolemic shock A client, who has sustained burns to the anterior chest and upper extremities, is brought to the burn center.During the initial stage of assessment, which nursing diagnosis is primary?Risk for Impaired Gas Exchange A patient has a burn injury that has destroyed all of the dermis and extends into the subcutaneous tissue, involving the muscle. This type of burn injury would be documented as which of the following?Full-thickness Which is the primary nursing intervention in the care of a client with burns exceeding 20% of total body surface area?Fluid resuscitation

The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to decrease catabolism.When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA?.5 Which of the following measures can be used to cool a burn?Application of cool water In a client with burns on the legs, which nursing intervention helps prevent contractures?Applying knee splints The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to promote which of the following?Decreased catabolism A client with a superficial partial-thickness solar burn (sunburn) of the chest, back, face, and arms is seen in

urgent care. The nurse's primary concern should be:

pain management.The nurse is providing care for a patent with a full- thickness, circumferential burn of the left lower leg.During the nurse's initial shift assessment, the patient is resting and the physical assessment of the left lower extremity is unremarkable. One hour later, the nurse notes the pulses of the left lower leg cannot be obtained by a Doppler ultrasound device, and the capillary refill of the left great toe is greater than 2 seconds. The nurse's best response based on the clinical findings is which of the following?Contact the primary care provider and prepare for an escharotomy.A child tips a pot of boiling water onto his bare legs. The

mother should:

Immerse the child's legs in cool water.A person suffers leg burns from spilled charcoal lighter fluid. A family member extinguishes the flames. While waiting for an ambulance, what should the burned person do?Have someone assist him into a bath of cool water, where he can wait for emergency personnel.A patient with a burn wound is prescribed mafenide acetate 5% (Sulfamylon) twice daily. Nursing implications associated with this medication include which of the following?Premedicating the patient with an analgesic prior to application A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult.The nurse anticipates which treatment management technique in the care of this client?Escharotomy