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Determining the depth of a burn is difficult initially because there are combinations of injury zones in the same location. The following describes one of the injury zones: the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. What is the name of that zone? A Zone of stasis |
Zone of stasis Explanation: The zone of stasis is the area of intermediate burn injury. It is here that blood vessels are damaged, but tissue has the potential to survive. The zone of coagulation is at the center of the injury, and it is the area where the injury is most severe and usually deepest. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. This is not the name of one of the zones. |
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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? A Superficial partial-thickness |
Full-thickness Explanation: A full-thickness burn involves total destruction of the dermis and extends into the subcutaneous fat. It can also involve muscle and bone. A superficial burn only damages the epidermis. In a superficial partial-thickness burn, the epidermis is destroyed and a small portion of the underlying dermis is injured. A deep partial-thickness burn extends into the reticular layer of the dermis and is hard to distinguish froma full-thickness burn. It is red or white, mottled, and can be moist or fairly dry. |
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A patient has been prescribed mafenide acetate (Sulfamylon) cream for burn treatment. The nurse should educate the patient regarding which of the following? A Can be left in place for 3 to 5 days |
Severe burning pain for up to 20 minutes Explanation: The patient should be premedicated with analgesic before applying mafenide acetate because this agent causes severe burning pain for up to 20 minutes after application. Silver nitrate stains everything it touches black. Acticoat dressings can be left in place for 3 to 5 days. Silver nitrate solution acts as a wick for sodium and potassium; serum levels of these electrolytes need to be monitored. |
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A patient is scheduled for an allograft to a burn wound. The patient asks what an allograft is. Which of the following information will the nurse include in the explanation? A "An allograft is a temporary wound covering obtained from pig skin." |
"An allograft is a temporary wound covering obtained from cadaver skin." Explanation: There are several different temporary and permanent coverings for burn wounds. Homografts (or allografts) and xenografts (or heterografts) are also referred to as biologic dressings and are intended to be temporary wound coverage. Homografts are skin obtained from recently deceased or living humans other than the patient. Xenografts consist of skin taken from animals (usually pigs). Therefore, the body’s immune response will eventually reject them as a foreign substance. |
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The nurse is caring for a patient with superficial partial-thickness burn injuries to the lower extremities. The patient is ordered IV morphine for pain. The nurse understands narcotics are given IV to manage pain during the initial management of pain because of which of the following? A Tissue edema may interfere with drug absorption via other routes. |
Tissue edema may interfere with drug absorption via other routes. Explanation: IV administration is necessary because of altered tissue perfusion from the burn injury. |
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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? A Monitoring the patient for the development of respiratory acidosis |
Premedicating the patient with an analgesic prior to application Explanation: Mafenide is a strong carbonic anhydrase inhibitor and may cause metabolic acidosis. Application may cause considerable pain initially, thus premedicating the patient is an appropriate intervention. The other nursing implications are not associated with mafenide. |
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A patient presents to the ED following a burn injury. The patient has burns to the anterior chest and entire left leg. Using the rule of nines, the nurse documents the total body surface area (TBSA) percentage as which of the following? A 27% |
36% Explanation: The rule-of-nines system is based on dividing anatomic regions, each representing approximately 9% of the TBSA, quickly allowing clinicians to obtain an estimate. If a portion of an anatomic area is burned, the TBSA is calculated accordingly—for example, if approximately half of the anterior leg is burned, the TBSA burned would be 4.5%. More specifically, with an adult who has been burned, the percent of the body involved can be calculated as follows: head = 9%, chest (front) = 9%, abdomen (front) = 9%, upper/mid/low back and buttocks = 18%, each arm = 9% (front = 4.5%, back = 4.5%), groin = 1%, and each leg = 18% total (front = 9%, back = 9%). |
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Acticoat antimicrobial barrier dressings used in the treatment of burn wounds can be left in place for which timeframe? A 2 days |
5 days Explanation: Acticoat antimicrobial barrier dressings can be left in place for up to 5 days thus helping to decrease discomfort to the patient, decrease costs of dressing supplies, and decrease nursing time involved in burn dressing changes. |
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Which of the following is the key sign of onset of ARDS? A Chest pain |
Hypoxemia Explanation: The key sign of the onset of ARDS is hypoxemia while receiving 100% oxygen, with decreased lung compliance and significant shunting. The physician should be notified immediately of deteriorating respiratory status. |
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ll of the following are antimicrobials commonly used to treat burns except: A Silver nitrate (AgNO3) 0.5% solution |
Tetracycline Explanation: Silver sulfadiazine (Silvadene), mafenide (Sulfamylon), and silver nitrate (AgNO3) 0.5% solution are the three major antimicrobials used to treat burns. |
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Which of the following topical burn preparations act as wick for sodium and potassium? A Mafenide acetate (Sulfamylon) |
Silver nitrate solution Explanation: Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. The other preparations do not act as a wick for sodium and potassium. |
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Which of the following provides clues about fluid volume status? Select all that apply. A Oxygen saturation |
Hourly urine output Daily weights Explanation: Monitoring of hourly urine output and daily weights provides clues about fluid volume status. Percentage of meals eaten, skin turgor, and oxygen saturation would not be reliable indicators of fluid volume status in the burn injured patient. |
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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? A Ca: 9 mg/dL |
BUN: 28 mg/dL Explanation: The elevated BUN would case the nurse the most concern. The nurse should report decreased urine output or increased BUN and creatinine values to the physician. These laboratory values indicate possible renal failure. In addition, myoglobinuria, which is associated with electrical burns, is common with muscle damage and may also cause kidney failure if not treated. The other values are within normal limits. |
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Which type of burn injury involves destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis? A Fourth degree |
Deep partial-thickness Explanation: A deep partial-thickness burn involves destruction of the epidermis and upper layers of the dermis and injury to deeper portions of the dermis. In a superficial partial-thickness burn, the epidermis is destroyed or injured and a portion of the dermis may be injured. Capillary refill follows tissue blanching. Hair follicles remain intact. A full-thickness burn involves total destruction of epidermis and dermis and, in some cases, destruction of underlying tissue, muscle, and bone. Although the term fourth-degree burn is not used universally, it occurs with prolonged flame contact or high voltage injury that destroys all layers of the skin and damages tendons and muscles. |
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Which type of débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar? A Natural |
Mechanical Explanation: Mechanical débridement involves the use of surgical scissors, scalpels, and forceps to separate and remove the eschar. Topical enzymatic débridement agents are available to promote débridement of the burn wounds. With natural débridement, the dead tissue separates from the underlying viable tissue spontaneously. Surgical débridement is an operative procedure involving either primary excision (surgical removal of tissue) of the full thickness of the skin down to the fascia (tangential excision) or shaving of the burned skin layers gradually down to freely bleeding, viable tissue. |
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Which of the following is an early sign of sepsis in the burn injured patient? A Clammy skin |
Widened pulse pressure Explanation: The signs of early systemic sepsis are subtle and require a high index of suspicion and very close monitoring of changes in the patient’s status. Early signs of sepsis may include increased temperature, increased pulse rate, widened pulse pressure, and flushed dry skin in unburned areas. |
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When the ED nurse learns that a patient suffered a burn injury from a flash flame, the nurse anticipates which depth of burn? A Deep partial thickness |
Deep partial thickness Explanation: A deep partial thickness burn, which is similar to a second-degree burn, is associated with scalds and flash flames. Superficial partial thickness burns, similar to first-degree burns are associated with sunburns. Full thickness burns, similar to third-degree burns, are associated with direct flame, electricity, and chemical contact. Injury from a flash flame is not associated with a burn that is limited to the epidermis. |
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Which of the following are possible indicators of pulmonary damage from an inhalation injury? Select all that apply. A Facial burns |
Singed nasal hair Hoarseness Facial burns Explanation: Indicators of possible pulmonary damage include singed nasal hair, hoarseness, voice change, stridor, burns of the face or neck, sooty or bloody sputum, and tachypnea. |
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The most important intervention in the nutritional support of a patient with a burn injury is to provide adequate nutrition and calories to A increase metabolic rate. |
decrease catabolism. Explanation: 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. Nutritional support with optimized protein intake can decrease the protein losses by approximately 50%. A marked increase in metabolic rate is seen after a burn injury and interventions are instituted to decrease metabolic rate and catabolism. A marked increase in glucose demand is seen after a burn injury and interventions are instituted to decrease glucose demands and catabolism. Rapid skeletal muscle breakdown with amino acids serving as the energy source is seen after a burn injury and interventions are instituted to decrease catabolism. |
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Following a burn injury, which of the following areas is the priority for nursing assessment? A Nutrition |
Pulmonary system Explanation: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs. |
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When using the palmar method to estimate the extent of the burn injury, the palm is equal to which percentage of TBSA? 1 3 |
.5 Explanation: In patients with scattered burns, or for a quick prehospital assessment, the palmer method may be used to estimate the extent of the burns. The size of the patient’s palm, not including the surface area of the digits, is approximately 0.5% of the TBSA. |
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Tom Benson, a 42-year-old electrical lineman, suffered significant burns in a workplace accident. During his airlift to a regional burn unit, you assess his wounds taking care to find and mark his entrance and exit wounds. What occurrence makes it difficult to assess internal burn damage in electrical burns? A Protein cell coagulation |
Deep tissue cooling Explanation: Because deep tissues cool more slowly than those at the surface, it is difficult initially to determine the extent of internal damage. |
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A patient is being discharged after sustaining a deep-partial thickness burn during a house fire. The patient is asking when the burn will be healed. The nurse understands that this type of burn injury heals within which of the following time frames? A 8 weeks |
2 to 4 weeks Explanation: For deep partial-thickness burn injuries, recovery is expected in 2 to 4 weeks. |
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The nurse understands that during the emergent/resuscitative phase of burn injury, hemoconcentration is due to which of the following? A Sodium and water retention caused by increase adrenocortical activity |
Liquid blood component is lost into extravascular space Explanation: Hemoconcentration is due to the blood component being lost into the extravascular space. Decreased urinary output occurs secondary to fluid loss, decreased renal blood flow, and sodium and water retention caused by increased adrenocortical activity. |
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The nurse is caring for a patient with extensive burn injuries. Which of the following parameters would the nurse evaluate to determine if the patient is receiving adequate fluid resuscitation? Select all that apply. A Heart rate |
Blood pressure Heart rate Urine output Explanation: Fluid resuscitation is administered to maintain adequate cardiac output and tissue perfusion. If adequate fluid is administered, tachycardia, hypotension, and oliguria will resolve. Expected outcomes of fluid resuscitation specifically include the following: urine output between 0.5 and 1.0 mL/kg/hr (30-50 mL/hr; 75 to 100 mL/hr if electrical burn injury), mean arterial pressure (MAP) pressure > 60 mm Hg, voids clear yellow urine with specific gravity within normal limits, and serum electrolytes are within normal limits |
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When is the first dressing change at the site of an autograft performed? A As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery |
As soon as foul odor or purulent drainage is noted, or 2 to 5 days after surgery Explanation: A foul odor or purulent infection may indicate infection and should be reported to the surgeon immediately. The first dressing change usually occurs 2 to 5 days after surgery. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively. |
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A 57-year-old firefighter was severely burned fighting a house fire. During his aggressive treatment, the client begins to exhibit symptoms of renal failure. What physiologic process can cause acute renal failure? A Hemoconcentration |
Hemoconcentration Explanation: The client with a burn experiences hemoconcentration when the plasma component of blood is lost or trapped. Myoglobin and hemoglobin are transported to the kidneys, where they may cause tubular necrosis and acute renal failure. |
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Several temporary and permanent sources are available for covering a burn wound. These may be manufactured synthetically, obtained from a biologic source, or a combination of the two. Select the graft described as the following: a biologic source of skin similar to that of the client. A Allograft |
Allograft Explanation: Allograft or homograft is a biologic source of skin similar to that of the client. A xenograft or heterograft is obtained from animals, principally pigs or cows. An autograft uses the client’s own skin, transplanted from one part of the body to another. A slit graft is a type of autograft. |
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At the scene of a fire, the first priority is to prevent further injury. What are interventions at the site that can help to prevent injury? Choose all that apply. A Roll the client in a blanket to smother the fire. |
Place the client in a horizontal position. Roll the client in a blanket to smother the fire. Explanation: If the clothing is on fire, the client is placed in a horizontal position and rolled in a blanket to smother the fire. |
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Which zone of burn injury sustains the most damage? A Middle |
Inner Explanation: Each burned area has three zones of injury. The inner zone (known as the area of coagulation, where cellular death occurs) sustains the most damage. The middle area, or zone of stasis, has a compromised blood supply, inflammation, and tissue injury. The outer zone, the zone of hyperemia, sustains the least damage. |
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ithin the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation? A All options are correct. |
Face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation. |
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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 4 |
1 Explanation: In patients with scattered burns, or for a quick prehospital assessment, the Palmer method may be used to estimate the extent of the burns. The size of the patient’s palm, not including the surface area of the digits, is approximately 1% of the TBSA. |
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The nurse has completed teaching home care instructions to a patient being discharged from the burn unit. Which of the following patient statements indicates the need for further teaching? A "I will wear sun block with the highest SPF possible to protect exposed burned skin from the sun." |
"As my wound heals, my skin will be itchy; I can apply lotion if scratching doesn’t help." Explanation: Itching is a normal part of healing. Many patients describe this as one of the most uncomfortable aspects of burn recovery. The patient can apply mild moisturizers to decrease itching from dryness. Medications can be discussed with your treatment team. The patient should pat the areas, scratching is contraindicated. The other statements indicate that teaching has been effective. |
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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? A Hypertension |
Inflammatory Explanation: The initial burn injury is further extended by inflammatory processes that affect layers of tissue below the initial surface injury. |
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Which of the following is the analgesic of choice for burn pain? A Fentanyl |
Morphine sulfate Explanation: Morphine sulfate remains the analgesic of choice. It is titrated to obtain pain relief on the patient’s self-report of pain. Fentanyl is particularly useful for procedural pain, because it has a rapid onset, high potency, and short duration, all of which make it effective for use with procedures. Demerol and Tylenol with codeine are not analgesics of choice for burn pain. |
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A patient is being cared for in a burn unit after suffering partial-thickness burns. The patient’s laboratory work reveals a positive wound culture for gram-negative bacteria. The health care provider orders silver sulfadiazine (Silvadene) to be applied to the patient’s burns. The nurse provides information to the patient about the medication. Which of the following statements made by the patient indicates an understanding about this treatment? Select all that apply. A "This medication will help my burn heal." |
"This medication is an antibacterial." "This medication will be applied directly to the wound." "This medication will help my burn heal." Explanation: This medication is an antibacterial, which has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. This medication is directly applied to the wound. This medication will not stain the patient’s skin, but it will help heal the patient’s burned areas. |
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Which of the following measures can be used to cool a burn? A Application of ice directly to burn |
Application of cool water Explanation: Once a burn has been sustained, the application of cool water is the best first-aid measure. Never apply ice directly to the burn, never wrap the person in ice, and never use cold soaks or dressings for longer than several minutes; such procedures may worsen the tissue damage and lead to hypothermia in people with large burns. |
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Which of the following fluid or electrolyte changes occur in the emergent/resuscitative phase? A Sodium excess |
Reduction in blood volume Explanation: A reduction in blood volume occurs secondary to plasma loss. Sodium deficit, potassium excess, and decreased urinary output occurs in this phase. |
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A patient has been prescribed Acticoat as a burn wound treatment. Which of the following is accurate regarding application of Acticoat? A Moisten with saline. |
Moisten with sterile water only. Explanation: Acticoat is moistened with sterile water only; never use normal saline. Do not use topical antimicrobials with Acticoat burn dressing. Keep Acticoat moist, not saturated. |
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Which of the following is a potential cause of a superficial partial-thickness burn? A Sunburn |
Sunburn Explanation: A potential cause of a superficial partial-thickness burn is a sunburn or low-intensity flash. Causes of deep partial-thickness burns are scalds and flash flames. Full-thickness burns may be caused by an electrical current or prolonged exposure to hot liquids. |
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The nurse is preparing to initiate fluid resuscitation for a patient weighing 130 pounds who suffered a 58% total body surface area (TBSA) thermal burn. The health care provider ordered: 2 mL lactated Ringer’s (LR) × patient’s weight in kilograms × %TBSA to be administered over 24 hours. The nurse will administer ________________________ mL of fluid over the first 8 hours post-burn injury? |
3422 Explanation: Convert pounds. to kilograms = 130/2.2 = 59 kg 2 mL × 59 kg × 58% TBSA = 6844 mL/24 hr. 6844/2 = 3422, so the nurse will administer 3422 mL over the first 8 hours and the remaining 3422 mL over the next 16 hours. The infusion is regulated so that one-half of the calculated volume is administered in the first 8 hours after burn injury. The second half of the calculated volume is administered over the next 16 hours. Fluid resuscitation formulas are only a guideline. It is imperative that the rate of infusion be titrated hourly as indicated by physiologic monitoring of the patient’s response. |
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A patient has undergone grafting following a burn injury. The nurse understands that the first dressing change at the site of an autograft is performed how soon after the surgery? A Within 12 hours after surgery |
2 to 5 days after surgery Explanation: The first dressing change usually occurs 2 to 5 days after surgery. In addition, a foul odor or purulence may indicate infection and should be reported to the surgeon immediately. Sanguineous drainage on a dressing covering an autograft is an anticipated abnormal observation postoperatively |
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Which of the following interventions helps to minimize the risk of further injury to an affected person at a scene of a fire? A Avoid immediate IV fluid therapy |
Roll the patient in a blanket Explanation: At the scene of a fire, the patient should be rolled in a blanket to smother the fire. The patient should be placed in a horizontal position to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passage. The patient should not be covered immediately with a wet cloth or kept in any position other than horizontal. However, IV fluid therapy should be administered en route to the hospital. |
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The nurse is caring for a 30-year-old female patient who suffered severe head and facial burn injuries. Which of the following actions, if completed by the patient, indicates she is adapting to her altered body image? Select all that apply. A Participates actively in daily activities |
Wears hats and wigs Participates actively in daily activities Explanation: The following are indicators that a patient is adapting to altered body image: verbalizes accurate description of alterations in body image and accepts physical appearance, demonstrates interest in resources that may improve function and perception of body appearance (e.g., uses cosmetics, wigs, and prostheses, as appropriate); socializes with significant others, peers, and usual social group; and seeks and achieves return to role in family, school, and community as a contributing member. Covering the face with a scarf indicates the patient is not adapting to the alteration in body image; absence of sleep disturbances is expected by the burn-injured patient but is not related to body image disturbance. |
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Which of the following is to be expected soon after a major burn? Select all that apply. A Tachycardia |
Hypotension Tachycardia Anxiety Explanation: Tachycardia, slight hypotension, and anxiety are expected soon after the burn. |
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When providing care to a client who has experienced multiple trauma, which of the following would be most important for the nurse to keep in mind? Injuries have occurred to at least three distinct organ systems. |
The client is assumed to have a spinal cord injury until proven otherwise. Explanation: With clients experiencing multiple trauma, the nurse must assume that the client has a spinal cord injury until proven otherwise. Multiple trauma cleints experience life-threatening injuries to at least two distinct organs or organ systems. Evidence of the trauma may be sparse or absent. Additionally, the injury that may seem the least significant may be the most lethal. |
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A nurse is providing an educational program for a group of occupational health nurses working in chemical facilities. Which of the following would the nurse include as the priority in the case of a chemical burn? Covering the area with a sterile dressing |
Rinsing the area with copious amounts of water Explanation: The priority for any chemical burn is to immediately drench the area with running water, unless the chemical is lye or white phosphorus, which should be brushed off the patient. Antimicrobial ointments, sterile dressings, and tetanus prophylaxis are measures instituted later in the course of treatment, depending on the characteristics of the chemical agent and the size and location of the burn. |
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Which of the following statements reflects the nursing management of the patient with a white phosphorus chemical burn? Alternate applications of water and ice to the burn |
Do not apply water to the burn Explanation: Water should not be applied to burns from lye or white phosphorus because of the potential for an explosion or deepening of the burn. |
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The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized? |
Full thickness Question 1 Explanation: The characteristics of the wound meet the criteria for a full-thickness injury (color that is black, brown, yellow, white or red; no blisters; pain minimal; outer layer firm and inelastic). |
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The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized? |
Partial-thickness superficial The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red; blisters; pain present and high). |
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The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route? The medication will be effective more quickly than if given intramuscularly. |
The danger of an overdose during fluid remobilization is reduced. Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics. |
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Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury? |
Vitamin D Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in full thickness burns. |
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Which client factors should alert the nurse to potential increased complications with a burn injury? The client is a 26-year-old male. |
The burned areas include the hands and perineum. Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome. |
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The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client’s family asks why this drug is being given, what is the nurse’s best response? "To increase the urine output and prevent kidney damage." |
"To decrease hydrochloric acid production in the stomach and prevent ulcers." Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid. |
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At what point after a burn injury should the nurse be most alert for the complication of hypokalemia? Immediately following the injury |
During fluid remobilization Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output. |
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What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire? Pulse oximetry reading of 80% |
Cherry red color to the mucous membranes The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a "cherry red" color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning. |
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What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn? |
Capillary refill is slow in the digits and the distal pulse is absent. Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy. |
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What additional laboratory test should be performed on any African American client who sustains a serious burn injury? |
Hemoglobin S electrophoresis Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client’s sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury. |
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Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery? |
Crystalloids Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer’s lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult. |
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The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s best first action? |
Loosen the dressing. Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status. |
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The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse’s best action? |
Notify the emergency team. Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard and neither are breath sounds. The client requires the establishment of an emergency airway and the swelling usually precludes intubation. |
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Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse’s best action? |
Document the finding as the only action. Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. |
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On admission to the emergency department the burned client’s blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury-related response? |
Fluid shift Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure. |
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Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse’s best action? Reposition the client onto the right side. |
Document the finding as the only action. Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time. |
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Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery? |
Increased urine output, decreased urine specific gravity The "fluid remobilization" phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity. |
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What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm? |
Risk for Disuse Syndrome During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury. |
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All of the following laboratory test results on a burned client’s blood are present during the emergent phase. Which result should the nurse report to the physician immediately? |
Serum potassium 7.5 mmol/L (mEq/L) All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. |
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The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission? |
Heart rate and rhythm The airway is not at any particular risk with this injury. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes. |
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In assessing the client’s potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission? |
"In what exact place or space were you when you were burned?" The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury. |
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Which information obtained by assessment ensures that the client’s respiratory efforts are currently adequate? The client is able to talk. |
The client’s oxygen saturation is 97%. Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range. |
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The burned client’s family ask at what point the client will no longer be at increased risk for infection. What is the nurse’s best response? "When fluid remobilization has started." |
"When the burn wounds are closed." Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open. |
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The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan? Seasonal asthma |
Myocardial infarction 1 year ago It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation. |
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The burned client on admission is drooling and having difficulty swallowing. What is the nurse’s best first action? Assess level of consciousness and pupillary reactions. |
Auscultate breath sounds over the trachea and mainstem bronchi Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly. |
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Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds? |
Handwashing on entering the client’s room Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only hand washing can prevent cross contamination. |
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In reviewing the burned client’s laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis? |
The "bands" outnumber the "segs." Normally, the mature segmented neutrophils ("segs") are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature "band" neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process. |
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The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury? |
Have the client turn the head from side to side 90 degrees every hour while awake. The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion. |
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The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint? Hip maintained in 30-degree flexion, no knee flexion |
Hip at zero flexion with leg flat Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion. |
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During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent? |
Increased serum creatinine level Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. |
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The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse’s best action? Nothing, because the findings are normal for clients during the acute phase of recovery. |
Notify the burn emergency team. These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention. |
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Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery? |
Changing gloves between wound care on different parts of the client’s body. Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client’s body can prevent autocontamination. |
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When should ambulation be initiated in the client who has sustained a major burn? When all full-thickness areas have been closed with skin grafts |
As soon as possible after resolution of the fluid shift Regular, progressive ambulation is initiated for all burn clients who do not have contraindications concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment. |
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What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures? "For the first few days after surgery, the donor sites will be painful." |
"Because the graft is my own skin, there is no chance it won’t ‘take’." Factors other than tissue type, such as circulation and infection, influence whether and how well a graft "takes." The client should be prepared for the possibility that not all grafting procedures will be successful. |
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Which statement by the client indicates correct understanding of rehabilitation after burn injury? "I will never be fully recovered from the burn." |
"I will be fully recovered when I achieve the highest possible level of functioning that I can." Although a return to pre burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. |
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Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment? "After this treatment, my ears will not stick out." |
"My facial scars should be less severe with the use of this mask." The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not change the angle of ear attachment to the head. |
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What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury? |
Impaired Adjustment Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem. |
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Nurse Faith should recognize that fluid shift in an client with burn injury results from increase in the: Total volume of circulating whole blood |
Permeability of capillary walls In burn, the capillaries and small vessels dilate, and cell damage cause the release of a histamine-like substance. The substance causes the capillary walls to become more permeable and significant quantities of fluid are lost. |
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Louie, with burns over 35% of the body, complains of chilling. In promoting the client’s comfort, the nurse should: Maintain room humidity below 40% |
Limit the occurrence of drafts A Client with burns is very sensitive to temperature changes because heat is loss in the burn areas. |
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