MSS Ch 12: Burns

Question 1

The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document?

1. Superficial partial thickness.
2. Deep partial thickness.
3. Full thickness.
4. First degree.

Answer 1

1. Sunburn is an example of this depth of burn; a superficial partial-thickness burn affects the epidermis and the skin is reddened and blanches with pressure.
2. Deep partial-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of the deeper dermis. This causes pain, blistered and mottled red skin, and edema.
3. Full-thickness burns are caused by flame, electric current, or chemical burns and include the epidermis, entire dermis, and sometimes subcutaneous tissue and may also involve connective tissue, muscle, and bone.
4. First-degree burn is another name for a superficial partial-thickness burn.

Question 2

The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer?

1. A 22-gauge intravenous line with normal saline infusing.
2. Wounds covered with moist sterile dressings.
3. No intravenous pain medication.
4. Adequate peripheral circulation to both feet ensured.

Answer 2

1. An 18-gauge catheter with lactated Ringer’s infusion should be initiated to maintain a urine output of at least 30 mL/hr.
2. Wounds should be covered with a clean, dry sheet.
3. The client should be transferred with ade- quate pain relief, which requires intravenous morphine.
4. The client’s legs should have pedal pulses and be warm to the touch, and the client must be able to move the toes.

Question 3

The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client?

1. Replace fluids and electrolytes.
2. Prevent contractures of extremities.
3. Monitor urine output hourly.
4. Prepare to assist with an escharotomy.

Answer 3

1. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes.
2. This is important, but it is not priority over fluid volume balance, and this is not a collaborative intervention because the nurse can do this independently.
3. Output must be monitored, but this is an independent intervention.
4. An escharotomy, an incision that releases scar tissue that prevents the body from being able to expand, enables chest excur- sion in circumferential chest burns. The client has not had time to develop eschar.

Question 4

The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client’s lower extremity burn. Which assessment data would require immediate attention by the nurse?

1. The client complains of pain when the medication is administered.
2. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L.
3. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
4. The client is able to perform active range-of-motion exercises.

Answer 4

1. The client should be premedicated with an analgesic because this agent causes severe burning pain for up to 20 minutes after application.
2. Silver nitrate solution is hypotonic and acts as a wick for sodium and potassium. Also, these electrolytes are WNL and would not require immediate intervention.
3. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. These ABGs indicate metabolic acidosis and therefore require immediate intervention.
4. The client being able to perform range-of-motion exercises does not warrant immedi- ate intervention; this is a very good result.

Question 5

The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, “What is a xenograft?” Which statement by the nurse would be the best response?

1. “The doctor will graft skin from your back to your leg.”
2. “The skin from a donor will be used to cover your burn.”
3. “The graft will come from an animal, probably a pig.”
4. “I think you should ask your doctor about the graft.”

Answer 5

1. This is the explanation for an autograft.
2. This is the description of a homograft.
3. A xenograft or heterograft consists of skin taken from animals, usually porcine.
4. This is “passing the buck”; the nurse can and should answer this question with factual information.

Question 6

The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?

1. High risk for infection.
2. Ineffective coping.
3. Impaired physical mobility.
4. Knowledge deficit.

Answer 6

1. Although this is a potential problem, it is priority because the body’s protective barrier, the skin, has been compromised and there is an impaired immune response.
2. This psychosocial client problem is important, but in the ICU the first priority is preventing infection so wound healing can occur.
3. Burn wound edema, pain, and potential joint contractures can cause mobility deficits, but the first priority is preventing infection so wound healing can occur.
4. Teaching is always important, but in the ICU the priority is the physiological integrity of the client.

Question 7

The nurse writes the nursing diagnosis “impaired skin integrity related to open burn wounds.” Which intervention would be appropriate for this nursing diagnosis?

1. Provide analgesia before pain becomes severe.
2. Clean the client’s wounds, body, and hair daily.
3. Screen visitors for respiratory infections.
4. Encourage visitors to bring plants and flowers.

Answer 7

1. Addressing pain will not address impaired skin integrity.
2. Daily cleaning reduces bacterial colonization.
3. This intervention would be appropriate for a “risk for infection” nursing diagnosis.
4. Plants and flowers in water should be avoided because stagnant water is a source for bacterial growth.

Question 8

Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.

1. Perform meticulous hand hygiene.
2. Use sterile gloves for wound care.
3. Wear gown and mask during procedures.
4. Change invasive lines once a week.
5. Administer antibiotics as prescribed.

Answer 8

1. Hand washing is the number-one intervention used to prevent infection, which is priority for the client with a burn.
2. Aseptic techniques minimize risk of cross- contamination and spread of bacteria.
3. Aseptic techniques minimize risk of cross- contamination and spread of bacteria.
4. Invasive lines and tubing should be changed daily.
5. Antibiotics reduce bacteria.

Question 9

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider?

1. The client is complaining of severe pain.
2. The client’s pulse oximeter reading is 95%.
3. The client has T 100.4 ̊F, P 100, R 24, and BP 102/60.
4. The client’s urinary output is 50 mL in two (2) hours.

Answer 9

1. Severe pain would be expected in a client with these types of burns; therefore, it would not warrant notifying the health-care provider.
2. A pulse oximeter reading greater than 93% is WNL. Therefore, a 95% reading would not warrant notifying the health-care provider.
3. The client’s vital signs show an elevated temperature, pulse, and respiration, along with a low blood pressure, but these vital signs would not be unusual for a client with severe burns.
4. Fluid and electrolyte balance is the priority for a client with a severe burn. Fluid resuscitation must be maintained to keep a urine output of 30 mL/hr. Therefore, a 25-mL/hr output would warrant immediate intervention.

Question 10

The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client’s nutritional status. Which intervention should the nurse implement?

1. Encourage the client’s family to bring favorite foods.
2. Provide a low-fat, low-cholesterol diet for the client.
3. Monitor the client’s weight weekly in the same clothes. 4. Make a referral to the hospital social worker.

Answer 10

1. The client needs sufficient nutrients for wound healing and increased metabolic requirements, and homemade nutritious foods are usually better than hospital food. This also allows the family to feel part of the client’s recovery.
2. The client should be provided a high- calorie, high-protein diet along with vitamins.
3. The client should be weighed daily, and the goal is that the client loses no more than 5% of preburn weight.
4. The nurse would make a referral to a dietitian, not a social worker.a

Question 11

The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client?

1. Apply an ice pack to the right hand.
2. Place the hand in cool water.
3. Be sure to rupture any blister formation.
4. Go immediately to the doctor’s office.

Answer 11

1. Ice should never be applied to a burn be- cause this will worsen the tissue damage by causing vasoconstriction.
2. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage.
3. Blisters should be maintained intact to prevent infection.
4. The client should be told to go to the ED, not the doctor’s office, for burn care.

Question 12

The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client’s mental health?

1. Encourage the client to stay at home as much as possible.
2. Discuss the importance of not relying on the family for needs.
3. Tell the client to remember that changes in lifestyle take time.
4. Instruct the client to discuss feelings only with the therapist.

Answer 12

1. The client should resume previous activi- ties gradually and should not stay home; the client should go out and begin to live again.
2. The client should be honest with self, family, and friends about needs, hopes, and fears.
3. The client needs to know that it will take time to adjust to life after burns and that returning to work, family role, sexual intimacy, and body image will take time.
4. The client should feel free to discuss feel- ings with family, friends, and the therapist.

Question 13

The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority.

1. Estimate the amount of burned area using the rule of nines.
2. Insert two (2) 18-gauge catheters and begin fluid replacement.
3. Apply sterile saline dressings to the burned areas.
4. Determine the client’s airway status.
5. Administer morphine sulfate, a narcotic analgesic, IV.

Answer 13

In order of priority: 4, 2, 3, 1, 5.

4. Airway is always the first priority for any process in which the airway might be compromised.
5. The nurse should start fluid resuscita- tion as soon as possible before the client’s blood pressure makes it more difficult to establish an IV route.
6. Covering the open burns will prevent further intrusion of bacteria.
7. Estimating the extent of the burned area should be done but does not have priority over airway, fluid replacement, and the prevention of infection.
8. Pain is priority but not over determining airway and fluid status and prevention of infection.