Integumentary: Saunders NCLEX Review, Burn Injuries, Disorders, Skin Integrity & Wound Care Leave the first rating Students also studied Terms in this set (156) Science

Integumentary: Saunders NCLEX Review, Burn Injuries,

Disorders, Skin Integrity & Wound Care Leave the first rating Students also studied Terms in this set (156) Science MedicineNursing Save Burns/NCLEX QUESTIONS 20 terms kidniki77Preview Comprehensive 180 terms ElMagoKikePreview ADH 100 terms ampannelPreview Integum 73 terms JTC The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first?

• Administer 100% humidified oxygen.
• Teach the patient deep breathing exercises.
• Encourage the patient to express his feelings.
• Assist the patient to a high Fowler's position.
• Administer 100% humidified oxygen.

Carbon monoxide (CO) poisoning may occur in house fires. CO displaces oxygen on the hemoglobin molecule resulting in hypoxia. High levels of CO in the blood result in a skin color that is described as cherry red. Hypoxia may cause anxious behaviors and altered mental status. Emergency treatment for inhalation injury and CO poisoning includes the immediate administration of 100% humidified oxygen. The other interventions are appropriate for inhalation injury but are not as urgent as oxygen administration.The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago.Which assessment findings would the nurse identify as congruent with this type of burn?

• Skin is hard with a dry, waxy white appearance.
• Skin is shiny and red with clear, fluid-filled blisters.
• Skin is red and blanches when slight pressure is

applied.

• Skin is leathery with visible muscles, tendons, and

bones.

• Skin is shiny and red with clear, fluid-filled blisters.

Deep partial thickness burns have fluid-filled vesicles that are red and shiny. They may appear wet (if vesicles have ruptured), and mild to moderate edema may be present. Superficial partial thickness burns are red and blanch with pressure vesicles that appear 24 hours after the burn injury. Full-thickness burns are dry, waxy white, leathery, or hard, and there may be involvement of muscles, tendons, and bones.

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg.Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change?

• Morphine sulfate
• Sertraline (Zoloft)
• Zolpidem (Ambien)
• Enoxaparin (Lovenox)
• Morphine sulfate

Deep partial-thickness burns result in severe pain related to nerve injury. The nurse should plan to administer analgesics before the dressing change to promote patient comfort. Morphine is a common opioid used for pain control.Sedative/hypnotics and antidepressant agents also can be given with analgesics to control the anxiety, insomnia, and/or depression that patients may experience.Zolpidem promotes sleep. Sertraline is an antidepressant. Enoxaparin is an anticoagulant.Which patient should the nurse prepare to transfer to a regional burn center?

• A 25-year-old pregnant patient with a

carboxyhemoglobin level of 1.5%

• A 39-year-old patient with a partial-thickness burn to

the right upper arm

• A 53-year-old patient with a chemical burn to the

anterior chest and neck

• A 42-year-old patient who is scheduled for skin

grafting of a burn wound

• A 53-year-old patient with a chemical burn to the anterior chest and neck

The American Burn Association (ABA) has established referral criteria to determine which burn injuries should be treated in burn centers where specialized facilities and personnel are available to handle this type of trauma (see Table 25-3). Patients with chemical burns should be referred to a burn center.A normal serum carboxyhemoglobin level for nonsmokers is 0% to 1.5% and for smokers is 4% to 9%. Skin grafting for burn wound management is not a criterion for a referral to a burn center. Partial-thickness burns greater than 10% total body surface area (TBSA) should be referred to a burn center. A burn to the right upper arm is 4% TBSA.The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply)

• Urine output is 80 mL/hour.
• Heart rate is 86 beats/minute.
• Urine specific gravity is 1.025.
• Mean arterial pressure is 54 mm Hg.
• Systolic blood pressure is 88 mm Hg.

A, B, C

• Urine output is 80 mL/hour.
• Heart rate is 86 beats/minute.
• Urine specific gravity is 1.025.

Assessment of the adequacy of fluid resuscitation is best made using either urine output or cardiac factors. Urine output should be at least 0.5 to 1 mL/kg/hr.Cardiac factors include a mean arterial pressure (MAP) > 65 mm Hg, systolic blood pressure (BP) > 90 mm Hg, heart rate < 120>

• An adult client was burned in an explosion. The burn

initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury?

1.18% 2.24% 3.36% 4.48% 3.36% Rationale:Accordingtotheruleofnines,withtheinitialburn,theanteriorhalfoftheheade quals4.5%,theupperhalfoftheanteriortorsoequals9%,andthelowerhalfofbotharmse quals9%.Thesubsequentburnincludedtheposteriorhalfofhead,equaling4.5%,andthe upperhalfofposteriortorso,equaling9%.Thistotals36%

• The nurse is preparing to care for a burn client

scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn.The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy?

1.Return of distal pulses 2.Brisk bleeding from the site 3.Decreasing edema formation 4.Formation of granulation tissue 1.Return of distal pulses

Rationale:Escharotomiesareperformedtorelievethecompartmentsyndromethatcan

occurwhenedemaformsundernondistensibleescharinacircumferentialthird- degreeburn.Escharotomiesareperformedthroughavasculareschartosubcutaneousf at.Althoughbleedingmayoccurfromthesite,itisconsideredacomplicationratherthana nanticipatedtherapeuticoutcome.Usually,directpressurewithabulkydressingandelev ationcontrolthebleeding,butoccasionallyanarteryisdamagedandmayrequireligatio n.Escharotomydoesnotaffecttheformationofedema.Formationofgranulationtissueis nottheintentofanescharotomy

• A client is undergoing fluid replacement after being

burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50mmHg, a pulse rate of 110 beats/minute, and a urine output of 20mL over the past hour. The nurse reports the findings to the healthcare provider (HCP) and anticipates which prescription?

1.Transfusing 1 unit of packed red blood cells 2.Administering a diuretic to increase urine output 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour 4.Changing the IV lactated Ringer's solution to one that contains dextrose in water 3.Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour

Rationale:Fluidmanagementduringthefirst24hoursfollowingaburninjurygenerallyinc

ludestheinfusionof(usually)lactatedRinger'ssolution.Fluidresuscitationisdetermined byurineoutputandhourlyurineoutputshouldbeatleast30mL/hour.Theclient'surineou tputisindicativeofinsufficientfluidresuscitation,whichplacestheclientatriskforinadeq uateperfusionofthebrain,heart,kidneys,andotherbodyorgans.ThereforetheHCPwou ldprescribeanincreaseintheamountofIVlactatedRinger'ssolutionadministeredperho ur.Bloodreplacementisnotusedforfluidtherapyforburninjuries.Administeringadiureti cwouldnotcorrecttheproblembecauseitwouldnotreplaceneededfluid.Diureticspro motetheremovalofthecirculatingvolume,therebyfurthercompromisingtheinadequat etissueperfusion.Dextroseinwaterisanisotonicsolution,andanisotonicsolutionmainta insfluidbalance.Thistypeofsolutionmaybeadministeredafterthefirst24hoursfollowin gtheburninjury,dependingontheclient's psychological needs.

512.A client is brought to the emergency department with partial thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client?Select all that apply.

1.Restrict fluids.

2.Assess for airway patency.

3.Administer oxygen as prescribed.

4.Place a cooling blanket on the client.

5.Elevate extremities if no fractures are present.

6.Prepare to give oral pain medication as prescribed.

2, 3, 5

2.Assess for airway patency.

3.Administer oxygen as prescribed.

5.Elevate extremities if no fractures are present.Rationale:Theprimarygoalforaburninjuryistomaintainapatentairway,administerIVflui dstopreventhypovolemicshock,andpreservevitalorganfunctioning.Thereforethepri orityactionsaretoassessforairwaypatencyandmaintainapatentairway.Thenursethenp reparestoadministeroxygen.Oxygenisnecessarytoperfusevitaltissuesandorgans.An IVlineshouldbeobtainedandfluidresuscitationstarted.Theextremitiesareelevatedtoa ssistinpreventingshock.TheclientiskeptwarmandplacedonNPOstatusbecauseofthe alteredgastrointestinalfunctionthatoccursasaresultofaburninjury 513.The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

1.Decreased heart rate 2.Increased urinary output 3.Increased blood pressure 4.Elevated hematocrit levels 4.Elevated hematocrit levels

Rationale:Theresuscitation/emergentphasebeginsatthetimeofinjuryandendswiththe

restorationofcapillarypermeability,usuallyat48to72hoursfollowingtheinjury.Duringt heresuscitation/emergentphase,thehematocritlevelincreasestoabovenormalbecau seofhemoconcentrationfromthelargefluidshifts.Hematocritlevelsof50%to55%areex pectedduringthefirst24hoursafterinjury,withreturntonormalby36hoursafterinjury.Ini tially,bloodisshuntedawayfromthekidneys,andrenalperfusionandglomerularfiltratio naredecreased,resultinginlowurineoutput.Pulseratesaretypicallyhigherthannormal, andthebloodpressureisdecreasedasaresultofthelargefluidshifts

515.A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client?

1.100% oxygen via an aerosol mask 2.Oxygen via nasal cannula at 6L/minute 3.Oxygen via nasal cannula at 15L/minute 4.100% oxygen via a tight-fitting, non rebreather face mask 4.100% oxygen via a tight-fitting, non rebreather face mask

Rationale:Ifaninhalationinjuryissuspected,administrationof100%oxygenviaatight-

fittingnonrebreatherfacemaskisprescribeduntilcarboxyhemoglobinlevelsfall(usuall ybelow15%).Ininhalationinjuries,theoropharynxisinspectedforevidenceoferythema, blisters,orulcerations.Theneedforendotrachealintubationalsoisassessed.Options1,2, and3areincorrectandwouldnotprovidethenecessaryoxygensupplyneededforadeq uatetissueperfusion.

516.The nurse is administering fluids intravenously as prescribed to a client who sustained superficial partial- thickness burn injuries of the back and legs. In evaluating the adequacy of fluid resuscitation, the nurse understands that which assessment would provide the most reliable indicator for determining the adequacy?

1.Vital signs 2.Urine output 3.Mental status 4.Peripheral pulse 2.Urine output Rationale:Successfuloradequatefluidresuscitationintheclientissignaledbystablevital signs,adequateurineoutput,palpableperipheralpulses,andclearsensorium.However ,themostreliableindicatorfordeterminingadequacyoffluidresuscitationistheurineout put.Foranadult,thehourlyurinevolumeshouldbe30to50mL

• The nurse manager is observing a new nursing

graduate caring for a burn client in protective isolation.The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique?

1.Using sterile sheets and linens 2.Performing strict hand washing technique 3.Wearing gloves and a gown only when giving direct care to the client 4.Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron 3.Wearing gloves and a gown only when giving direct care to the client

Rationale:Thoroughhandwashingshouldbedonebeforeandaftereachcontactwiththe

burn- injuredclient.Sterilesheetsandlinensareusedbecauseoftheclient'shighriskforinfectio n.Protectivegarb,includinggloves,cap,masks,shoecovers,gowns,andplasticapron,n eedtobewornwhenintheclient'sroomandwhendirectlycaringfortheclient 518.The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client?

1.Out-of-bed activities 2.Bathroom privileges 3.Immobilization of the affected leg 4.Placing the affected leg in a dependent position 3.Immobilization of the affected leg

Rationale:Autograftsplacedoverjointsoronthelowerextremitiesaftersurgeryoftenar

eelevatedandimmobilizedfor3to7days.Thisperiodofimmobilizationallowstheautogr afttimetoadheretothewoundbed.Options1,2,and4areincorrect incidence of burns~ 200,000 burns/year reported in Canada 5% require hospitalization In Ontario burns account for 1000 hospitalizations/year and 10,800 hospital days Mortality rate ~90% if >60 years of age, TBSA>40%, and inhalation injury