Burns

CARE OF THE CLIENTS WITH BURNS Prepared by: ROBERT C. REÑA, BSN, RN, MAN (ue) For the greater glory of god!

1. A nursing instructor has just completed a lecture

to nursing students regarding care of the client with a burn injury, and a major aspect of the lecture was care of the client at the scene of a fire. Which statement if made by a nursing student indicates a need for further instruction? a. b. c. d.

Flames may be extinguished by rolling the client on the ground. Flames may be smothered by the use of a blanket or another cover. Flames should be doused with water. The client should be maintained in a standing position because the flames may spread to the other parts of the body.

6.

a. b. c. d. 7.

2. A community health nurse is providing a

teaching session to firefighters in a small community regarding care of a burn victim at the scene of injury. The nurse instructs the firefighters that in the event of a tar burn, the immediate action should be: a. b. c. d.

Cool the injury with water. Removing all clothing immediately. Removing the tar from the injury. Leaving any clothing that is saturated with tar in place.

8.

a.

Leaving all clothes clothes in place until the client is brought to the emergency department. b. Removing all clothing including gloves and shoes. c. Lavaging the skin with water water and avoid brushing powdered chemical off the clothing to prevent further spread of the injury. d. Determining the antidote for the chemical and and placing the antidote on the burn site. 4. A client who sustained an inhalation injury

arrives in the emergency department. On initial assessment, the nurse notes that the client is confused and combative. The nurse determined that the client is experiencing: a. Anxiety b. Fear  c. Hypoxia d. Pain 5. An emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the physician¶s orders and plans to question an order for which of the following? a. b. c. d.

Nothing by mouth (NPO) status Gastric lavage Intravenous fluid therapy Preparation for barium swallow

36% 45% 54% 63%

An emergency department nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which of the following assessments would be the initial priority in caring for this client? a. b. c. d.

Assessing peripheral pulses Assessing respiratory rate Assessing heart rate Assessing blood pressure

A client who is being evaluated for thermal burn injuries to the arms and leg complains of thirst and asks the nurse for a drink. Which action by the nurse is appropriate? a. Give the client small glasses of clear liquids. b. Keep the client on nothing by mouth (NPO) status. c. Allow the client to have full liquids d. Order the client a full meal meal tray with extra extra fluids. fluids.

3. An industrial nurse is providing instructions to a

group of employees regarding care to a client in the event of a chemical burn injury. The nurse instructs the employees that the first consideration in immediate care is:

The client sustains a burn injury inju ry to the entire right and left arms, the right leg, and the anterior  thorax. According to the Rule of Nines, the nurse would assess that this injury constitutes which body percentages?

9.

There has been a fire in an apartment building. All residents have been evacuated, but many are burned. Which client should be transported to a burn center for treatment? 1. An 8-year-old 8-year-old with with third-degree third-degree burns over 10% of his body surface area (BSA). 2. A 20-year-old 20-year-old who who inhaled the smoke smoke of of the fire. 3. A 50-year-old diabetic with with first- and and seconddegree burns on his left forearm (about 5% of  his BSA). 4. A 30-year-old 30-year-old with with second-degree second-degree burns on the back of his leg. 5. A 40-year-old with second-degree burns on his right arm (about 5% of his BSA). a. b. c. d.

All of them 1, 2, and 3 1, 2, 4, and 5 1, 2, 3, and 4

10. The nurse in the immediate care clinic is

assessing an 80-year-old client who lives with his son¶s family and has scald burns on his hands and both forearms (first- and seconddegree burns on 10% of his body surface area). What should the nurse do first? a. b. c. d.

Clean the wounds with warm water. Apply antibiotic cream. Refer the client to a burn center. Cover the burns burns with a sterile sterile dressing.

11. The nurse assesses the client for fluid shifting.

Fluid shifts that occur during the emergent Care of the Clients with Burns

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phase of a burn injury are caused by fluid moving: a. b. c. d.

From the vascular to the interstitial space. From the extracellular to the intracellular space. From the intracellular to the extracellular space. From the interstitial to the vascular space.

12. The nurse should recognize that fluid shift in a

client with a burn injury results from an increase in the: a. b. c. d.

Permeability of the capillary walls. Total volume of intravascular plasma. Total volume of circulating whole blood. Permeability of the kidney tubules.

13. A priority nursing diagnosis for a client with

burns during the emergent period would be: a. b. c. d.

Excess fluid volume Imbalanced nutrition: requirements Risk for injury (falling) Risk for infection

Less

than

body 

Soak the dressing. Remove the dressing. Administer an analgesic. Slit the dressing with blunt scissors.

15. The client with a major burn injury receives total

parenteral nutrition (TPN). The primary reason for this therapy is to help: Correct water and electrolyte imbalance. Allow the gastrointestinal tract to rest. Provide supplemental vitamins and minerals. Ensure adequate caloric and protein intake.

16. The client asks the nurse what the word

eschar 

means. Which of the following descriptions by the nurse best defines eschar? a. b. c. d.

³Eschar is scar tissue in a developmental stage.´ ³Eschar is crust formation without a blood supply.´ ³Eschar is burned tissue that has become infected.´ ³Eschar is visible living tissue with a rich blood supply.´

17. An advantage of using biologic burn grafts such

as porcine (pigskin) grafts is that they appear to help: a. b. c. d.

Encourage formation of tough skin. Promote the growth of epithelial tissue. Provide for permanent wound closure. Facilitate development of subcutaneous tissue.

18. Which of the following factors would have the

influence on the survival and effectiveness of a burn victim¶s porcine graft? l east 

a. b. c. d.

Absence of infection in the wounds. Adequate vascularization in the grafted area. Immobilization of the area being grafted. Use of analgesics as necessary for pain relief.

19. The nurse should plan to begin rehabilitation

efforts for the burn client: a.

cell destruction resulting in a disruption of the normal homeostasis of the body. The nurse anticipates that the client will be susceptible to which of the following in the early phase of burn care? a. b. c. d.

Hypernatremia Hyponatremia Metabolic alkalosis Hyperkalemia

clients who have experienced:

nurse include in the plan of care for a client with burn injuries to be carried out about one-half  hour before the daily whirlpool bath and dressing change?

a. b. c. d.

20. When an individual is burned, there is massive

21. Endotracheal or tracheostomy tubes are place in

14. Which of the following activities should the

a. b. c. d.

b. After the client¶s circulatory status has been stabilized. c. After grafting of the burn wounds has occurred. d. After the client¶s pain has been eliminated.

a. Electrical burns of the hands and arms causing arrhythmias. b. Thermal burns to the head, face, and airway resulting in hypoxia. c. Chemical burns on the chest and abdomen. d. Secondhand smoke inhalation. 22. A nurse has developed a nursing diagnosis of 

ineffective airway clearance for a client who sustained an inhalation burn injury. Which of the following nursing interventions should the nurse include in the plan of care of this client? a. Monitor oxygen saturation levels every 4 hours. b. Encourage coughing and deep breathing every 4 hours. c. Elevate the head of the bed. d. Assess respiratory rate and breath sounds every 4 hours. 23. A newly burned client is admitted to the unit. The

nurse measures the client¶s urine output on an hourly basis. Which of the following hourly urine output rates will alert the nurse to potential problems? a. b. c. d.

20 ml/hr  30 ml/hr  50 ml/hr  100 ml/hr 

24. The nurse is caring for a client who sustained

superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of  the following does the nurse expect to note during the emergent phase of the burn injury? a. b. c. d.

Decreased heart rate Increased urinary output Increased blood pressure Increased haematocrit levels

25. After the initial phase of the burn injury, the

client¶s plan of care will focus primarily on: a. Helping the client maintain a positive selfconcept. b. Promoting hygiene. c. Preventing infection. d. Educating the client regarding care of the skin grafts. 26. The burned client needs fluid replacement

because massive amounts of fluids are lost. The rate at which I.V. fluids are infused is based on the burn client¶s:

Immediately after the burn has occurred.

Care of the Clients with Burns

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a. b. c. d.

Lean muscle mass and body surface area (BSA) burned. Total body weight and BSA burned. Body mass index and BSA burned. Degree of burn injury and BSA burned.

27. A client sustained a burn injury at 7 AM. The

client¶s spouse states that before the burn, his body weight was 198 pounds (90 kg). The physician has estimated that the total body surface area burned is 83%. Using the Parkland (Baxter) formula, the nurse determines that the total amount of intravenous lactated Ringer¶s solution that the client will receive by 3 PM of the same day that the burn occurred is which of the following? a. b. c. d.

3735 mL 7470 mL 14,940 mL 29,880 mL

which of the following would provide the most reliable indicator for determining the adequacy? a. b. c. d.

Vital signs Urine output Mental status Peripheral pulses

33. The head nurse is observing a newly registered

nurse caring for a burn client in protective isolation. The head nurse intervenes if the newly registered nurse planned to implement which incorrect component of protective isolation technique? a. Using sterile sheets and linens b. Performing strict hand-washing technique c. Wearing gloves and a gown only when giving direct care to the client. d. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron

28. A client is undergoing fluid replacement after 

34. The nurse is caring for a client following an

being burned on 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats/min, and a urine output of 20 mL over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders to be prescribed?

autograft and grafting to a burn wound on the right knee. Which of the following would the nurse anticipate to be prescribed for the client?

a. b. c. d.

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

29. When caring for a client with extensive burns,

the nurse anticipates that pain medication will be administered via which route? a. Oral b. Intravenous c. Intramuscular  d. Subcutaneous 30. The client arrives at the emergency room

following a burn injury that occurred in the at home and an inhalation injury is suspected. Which of the following would the nurse anticipate to be prescribed for the client? a. b. c. d.

100% oxygen via an aerosol mask Oxygen via nasal cannula at 15 L/min Oxygen via nasal cannula at 10 L/min 100% oxygen via a tight-fitting, nonrebreather  face mask

31. The nurse is caring for a client who suffered an

a. b. c. d.

Out of bed Bathroom privileges Immobilization of the affected leg Placing the affected leg in a dependent position

35. A nurse is performing an assessment on a client

being admitted to the nursing unit who has sustained an extensive burn injury involving greater than 25% of total body surface area (TBSA). In performing the assessment, the nurse knows that the maximum amount of edema that occurs from a burn normally is seen: a. b. c. d.

Immediately after the injury Within 12 hours after the injury Between 18 and 24 hours after the injury Between 42 and 42 hours after the injury

36. The nurse is caring for a client with a burn injury

and understands that stress reactions can result in hypersecretion of gastric acids. Therefore, the nurse must assess the client for signs and symptoms of which of the following potential complications? a. b. c. d.

Paralytic ileus Gastric distention Hiatal hernia Curling¶s ulcer 

Keep your inner flame burning brightly  to accomplish yourR.N. dream!

inhalation injury from a wood stove. The carbon monoxide blood report reveals a level of 12%. Based on this level, the nurse would anticipate which of the following signs in the client? a. Coma b. Flushing c. Dizziness d. Tachycardia 32. 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

Care of the Clients with Burns

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