Question 1

The nurse is caring for a client who has partial-thickness burns. Which of the following prescribed medications will be best for the nurse to use before wound debridement?

Accepted Answer

Opioid pain medications are the best choice for pain control. The other medications are used as adjuvants to enhance the effect of opioids.

Question 2

The nurse is caring for a client who is in the emergent phase of burn care. Which of the following nursing actions will be most useful in determining whether the client is receiving adequate fluid infusion?

Accepted Answer

When fluid intake is adequate, the urine output will be at least 0.5-1 mL/kg/hour. The client's weight is not useful in this situation because of the effects of third spacing and evaporative fluid loss. Mucous membrane assessment and skin turgor also may be used, but they are not as adequate in determining that fluid infusions are maintaining adequate perfusion.

Question 3

Which of the following snacks will be best for the nurse to offer to a client with burns covering 40% total body surface area (TBSA) who is in the acute phase of burn treatment?

Accepted Answer

A client with a burn injury needs high protein and calorie food intake, and the milkshake is the highest in these nutrients. The other choices are not as nutrient-dense as the milkshake.

Question 4

Six hours after a thermal burn covering 50% of a client's total body surface area (TBSA), the nurse obtains these data when assessing a client. Which of the following information is priority for the nurse to communicate to the health care provider?

Accepted Answer

The urine output should be at least 0.5-1.0 mL/kg/hour during the emergent phase, when the client is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 systolic, and the pulse rate should be less than 120. Serous exudate from the burns is expected during the emergent phase.

Question 5

Which of the following actions should be included in the plan of care for a client who has burns of the ears, head, neck, and right arm and hand?

Accepted Answer

The right hand and arm should be elevated to reduce swelling and the fingers extended to avoid flexion contractures (even though this position may not be comfortable for the client). The client with burns of the ears should not use a pillow since this will put pressure on the ears and may stick to the ears. Clients with neck burns should not use a pillow, since the head should be maintained in an extended position in order to avoid contractures.

Question 6

The nurse is admitting a client to the burn unit who has an approximate 25% total body surface area (TBSA) burn and the following initial laboratory results: Hct 56%, Hb 172 g/L, serum K+ 4.8 mmol/L, and serum Na+ 135 mmol/L. Which of the following actionsshould the nurse anticipate implementing?

Accepted Answer

The client's laboratory data show hemoconcentration, which may lead to a decrease in blood flow to the microcirculation unless fluid intake is increased. Documentation and continuing to monitor are inadequate responses to the data. Since the hematocrit and hemoglobin are elevated, a transfusion is inappropriate, although transfusions may be needed after the emergent phase.

Question 7

The nurse is caring for a client who has just been admitted with a 40% total body surface area (TBSA) burn injury. Which of the following interventions should the nurse include in the plan of care to maintain adequate nutrition?

Accepted Answer

Enteral feedings can usually be initiated during the emergent phase at low rates and increased over 24-48 hours to the goal rate. During the emergent phase, the client will be unable to eat enough calories to meet nutritional needs and may have a paralytic ileus that prevents adequate nutrient absorption. Vitamins and minerals may be administered during the emergent phase, but these will not assist in meeting the client's caloric needs.
Parenteral nutrition increases the infection risk, does not help preserve gastrointestinal function, and is not routinely used in burn clients.

Question 8

The nurse is assessing a client who spilled hot oil on the right leg and foot and notes that the skin is red, swollen, and covered with large blisters. The client states that they are very painful. Which of the following burn descriptions should the nurse document?

Accepted Answer

The erythema, swelling, and blisters point to a deep partial-thickness burn. With
full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. With superficial partial-thickness burns, the area is red, but no blisters are present.

Question 9

Which of the following assessment parameters is the priority nursing assessment when caring for a client who has just arrived in the emergency department after suffering an electrical burn from exposure to a high-voltage current?

Accepted Answer

All clients with electrical burns should be considered at risk for cervical spine injury, and assessments of extremity movement will provide baseline data. The other assessment data also are necessary but not as essential as determining cervical spine status.

Question 10

Which of the following actions should the nurse take first when a client arrives in the emergency department with facial and chest burns caused by a house fire?

Accepted Answer

A client with facial and chest burns is at risk for inhalation injury, and assessment of airway and breathing is the priority. The other actions will be completed after airway management is assured.

Question 11

The nurse is caring for a client who has burns over 30% of the body surface. Which of the following events indicates that the client has moved from the emergent to the acute phase of the burn injury?

Accepted Answer

At the end of the emergent phase, capillary permeability normalizes and the client begins to diurese large amounts of urine with a low specific gravity. Although this may occur at about 48 hours, it may be longer in some clients. Blisters and edema begin to resolve, but this process requires more time. White blood cells may increase or decrease, based on the client's immune status and any infectious processes.

Question 12

The nurse is caring for a client who is in the rehabilitation phase after havingdeep partial-thickness face and neck burns and has a nursing diagnosis of disturbed body image. Which of the following actions by the client indicates that the problem is resolving?

Accepted Answer

The willingness to use strategies to enhance appearance is an indication that the disturbed body image is resolving. Expressing feelings about the scars indicates a willingness to discuss appearance, but not resolution of the problem. Because deep partial-thickness burns leave permanent scars, a statement that the scars are temporary indicates denial rather than resolution of the problem. Avoiding using a pillow will help prevent contractures, but it does not address the problem of disturbed body image.

Question 13

The nurse is caring for a client who has circumferential burns of both arms and develops a decrease in radial pulse strength and numbness in the fingers. Which of the following actions should the nurse take?

Accepted Answer

The decrease in pulse in a client with circumferential burns indicates decreased circulation to the arms and the need for escharotomy. Monitoring the pulses is not an adequate response to the decrease in circulation. Elevating the hands or increasing hand movement will not improve the client's circulation.

Question 14

The nurse is caring for a client who has burns on the back and chest from a house fire and has become agitated and restless 9 hours after being admitted to the hospital. Which of the following actions should the nurse take first?

Accepted Answer

Agitation in a client who may have suffered inhalation injury might indicate hypoxemia, and this should be assessed by the nurse first. Administration of morphine may be indicated if the nurse determines that the agitation is caused by pain. Assessing level of consciousness and orientation also is appropriate but not as essential as determining whether the client is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic client.

Question 15

The nurse is caring for a client who incurred extensive burn injuries 5 days ago and has been prescribed ranitidine. Which of the following assessments should the nurse use to evaluate the effectiveness of the medication?

Accepted Answer

H2 blockers are given to prevent Curling's ulcer in the client who has suffered burn injuries. H2 blockers do not impact bowel sounds, stool frequency, or appetite.

Question 16

The nurse is admitting a client to the burn unit who has burns to the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased and no wheezes are audible. Which of the following actions should thenurse implement first?

Accepted Answer

The client's history and clinical manifestations suggest airway edema and the health care provider should immediately be notified so that intubation can rapidly be done. Placing the client in a more upright position or having the client cough will not address the problem of airway edema. Continuing to monitor is inappropriate because immediate action should occur.

Question 17

The occupational health nurse is assessing an employee who has just spilled industrial acids on the arms and legs. Which of the following actions is priority for the nurse to implement?

Accepted Answer

With chemical burns, the initial action is to remove the chemical from contact with the skin as quickly as possible. Covering the affected area or placing cool compresses on the area will leave the chemical in contact with the skin. Application of an alkaline solution is not recommended.

Question 18

The nurse is caring for a client with severe burns who is receiving crystalloid fluid replacement IV, ordered using the Parkland formula. The initial volume of fluid to be administered in the first 24 hours is 30 000 mL. The initial rate of administration is 1875 mL/hour. Which of the following infusion rates is accurate after the first 8 hours?

Accepted Answer

Half of the fluid replacement using the Parkland formula is administered in the first 8 hours and the other half over the next 16 hours (25% per each 8 hour period, respectively). In this case, the client should receive half of the initial rate, or 938 mL/hour.

Question 19

The nurse is admitting a client with extensive electrical burn injuries. Which of the following prescribed interventions should the nurse implement first?

Accepted Answer

After an electrical burn, the client is at risk for fatal dysrhythmias and should be placed on a cardiac monitor. The other actions should be accomplished in the following order: Start two IVs, assess for pain, and apply dressings.

Question 20

The nurse is caring for a client who has deep partial-thickness and full-thickness burns of the face and chest and is having the wounds treated with the open method. Which of the following nursing actions should be included in the plan of care?

Accepted Answer

Use of gowns, caps, masks, and gloves during all client care will decrease the possibility of wound contamination for a client whose burns are not covered. Restricting all visitors is not necessary and will have adverse psychosocial consequences for the client. The room temperature should be kept at approximately 30°C (86°F) for clients with open burn wounds. Systemic antibiotics are not well absorbed into deep burns because of the lack of circulation.

Quiz 27: Nursing Management Burns