ATI
A nurse is caring for a client who has a major burn injury and is experiencing third spacing. Which of the following fluid or electrolyte imbalances should the nurse expect?
A. Hypokalemia
B. Hypernatremia
C. Elevated Hct
D. Decreased Hgb
Correct Answer: C. Elevated Hct
The nurse should expect a client who is experiencing third spacing resulting from a major burn to have an elevated hematocrit level as blood
volume is reduced by vascular dehydration.
Incorrect Answers:
D. The nurse should expect the client to have an increased hemoglobin level as blood volume is reduced by vascular dehydration.
A nurse is caring for an adolescent client who has burn wounds on her face and hands. Which of the following statements by the client indicates that she has adapted to her changed body image?
A. "May I go with my family to the visitor's lounge?"
B. "I'll see my friends when I get home."
c. "My dad is coming to visit. Can you fix my hair for me?"
D. "I told my cousins l'm in protective isolation."
Close Explanation
Correct Answer: A. "May I go with my family to the visitor's lounge?"
This statement demonstrates a positive self-image since the client is asking to visit with her family in a public setting.
Incorrect Answers:
An ambulance brought a client removed from a burning house fire. The client is in hypovolemic shock. Which of these IV solutions should be administered immediately?
A. LR
B. D5W
C.0.45 NS
D. D5LR
Answer: A
D5W is dextrose in water is a hypotonic solution.
0.45 Normal Saline is a hypotonic solution.
D5LR is a hypertonic solution.
A client has just arrived to the Emergency Department and has sustained burns on the front and back of the right arm and leg.
1. 27%
2. 18%
3. 36%
4. 9%
27%
Rationale
A nurse can estimate the % of the body area burned using the rule of 9's. Each arm (front and back) is 9% each leg is 9% front and 9% back.
A nurse is teaching a client who has extensive deep partial- and full-thickness burns and requires a topical antimicrobial medication. The goal of this medication therapy is to reduce which of the following outcomes?
A. Bacterial growth
B. Scarring
C. Skin graft size
D. Pain
A
A nurse is caring for a client who has burn injuries on his trunk. The nurse is explaining what to expect from the prescribed hydrotherapy. Which of the following statements by the client indicates an understanding of the teaching?
Close Explanation
Correct Answer: A. "I will be on a special shower table."
The special shower table facilitates examination and debridement of the wound during hydrotherapy. An advantage of using the showering technique as opposed to a tub bath is that the water can be kept at a constant temperature; there is also a lower risk of wound infection.
Incorrect Answers:
A client is brought to the hospital with fluid-filled shiny blisters over the trunk, arms, legs, and perineum that are extremely painful. Which type of burn is the client experiencing?
A. First degree
B. Second degree
C. Third degree
D. Fourth degree
B.
first-degree burns appear red, but have no blisters. Second-degree burns affect the first layer of skin and extend to the dermis and are usually red, shiny, with fluid-filled blisters, and extremely painful. Both are partial-thickness burns.
third-degree burns extend through the subcutaneous layer of skin and may appear dry, waxy, white leathery, or charred black in color
fourth-degree burns extend into the muscle and bone and usually have no pain since the nerve receptors are destroyed. Fourth-degree burns may appear white or black and charred and may have eschar formation.
A patient is brought into the emergency department after suffering from third degree burns in an explosion. The patient has burns on approximately 40 percent of his body. The nurse weighs the patient and notes that he weighs 170 lbs. Calculate the volume of IV fluid this patient must receive in the first 24 hours using the Parkland formula.
1. 12 L
2. 4 L
3. 8 L
4. 16 L
1. 12L
Rationale
"12 L" is correct. The Parkland formula is a method of calculating the amount of fluid needed for fluid resuscitation after a burn injury. To use the Parkland formula, the nurse must know the weight of the patient in kg and the approximate size of the burn. The Parkland formula is as follows: Fluid requirement (mL) = (4 mL of crystalloid) × (% TBSA burned) × body weight (kg). 170 lbs = 77 kg. Therefore, 4 x 40 x 77 = 12,320 mL fluid. So 12,000 mL = 12 L fluid needed in the first 24 hours. The first half of the result should be given in the first 8 hours, with the second half of the result given in the following 16 hours.
A nurse is caring for a client who has a prescription for silver sulfadiazine cream to be applied to her burn wounds. The nurse should evaluate the client for which of the following laboratory findings?
Close Explanation
Correct Answer: B. Leukopenia
Transient leukopenia is an adverse effect of silver sulfadiazine.
Incorrect Answers:
A. Silver sulfadiazine does not cause an electrolyte imbalance.
A nurse is caring for a client whose wounds are covered with a heterograft dressing. In response to the client's questions about the dressing, the nurse explains that it is obtained from which of the following sources?
Correct Answer: B. Pig skin
Heterografts are obtained from an animal, usually a pig.
Incorrect Answers:
A. Homographs are obtained from cadaver skin.
A client comes into the Emergency Department (ED) with full-thickness electrical burns covering the hands, arms, and frontal trunk. According to the Rule of 9’s, what is the client’s total body surface area (TBSA)?
A. 18%
B.25%
C.30%
D.36%
D
The rule of 9’s divides the body into percentages. Each arm including each hand is 9% each; the anterior trunk is 18%; posterior trunk is 18%; the head and neck are 9%, perineum or genitalia is only 1%; and legs with the feet are 18% each. The total body surface area (TBSA) is how much of the total body was burned. A full-thickness burn penetrates all the skin layers, which include the epidermis, the dermis, through the subcutaneous layer, muscle, and even bone.
A client is rushed to the emergency room after having a 500 pound steel container fall onto their left side, spilling hazardous material all over the clients face. The chemical is burning the clients face and the client is losing their airway. The nurse gowns up into the hazmat suit and makes sure it is safe to enter the hazmat room. What is the nurses priority at this time?
1. Maintain the clients airway
2. Pour water over the client and remove all hazerdous material
3. Get a set of vital signs
4. Give the patient oxygen
Pour water over the client and remove all hazardous material.
In a hazardous material exposure, the priority is decontamination before treatment. If the chemical remains on the patient, it will continue causing tissue damage and can also expose healthcare workers.
A nurse is evaluating the laboratory values of a client who is in the resuscitation phase following a major burn. Which of the following laboratory findings should the nurse expect?
Close Explanation
Correct Answer: B. Sodium 132 mEq/L
This laboratory finding is below the expected reference range. The nurse should anticipate a low sodium level because sodium is trapped in interstitial space.
Incorrect Answers:
A. This laboratory value is below the expected reference range. The nurse should anticipate an elevated hemoglobin level during the resuscitation phase due to the loss of fluid volume.
A nurse is planning to administer fluids to a client who has 25% total body surface area burns. The client has no prior medical history. Which of the following intravenous fluids is contraindicated for this client?
Correct Answer: D. 0.45% sodium chloride
The nurse should identify that 0.45% sodium chloride is a hypotonic solution and is contraindicated for clients who have burns. Hypotonic fluid has an osmolarity value of <270 mOsm/L, which is less than the expected reference range of the osmolarity value for plasma and body fluid of 285 to 295 mOsm/L. Administering a hypotonic solution to this client can cause third-spacing of fluid.
Incorrect Answers:
A client arrives at the hospital with full-thickness burns to the front and back of the right and left leg, the back of the right arm, and the anterior trunk. Upon arrival, the client’s weight is 63 kg. Using the Parkland Burn Formula, how much IV fluids should the client receive during the first 24 hours?
A. 11,340 ML
B. 13,104ML
C. 14,144 ML
D. 14,742ML
D.
The front and back of the client’s right and left leg (18% each) would be 36%; back of the right arm would be 4.5%; and the anterior trunk would be 18%. 36% + 4.5% + 18% = 58.5% TBSA. 4 ml X 58.5% X 63 kg = 14,742 ml.
A patient who has burns on the arms, legs, and chest from a house fire has become agitated and restless 8 hours after being admitted to the hospital. Which action should the nurse take first?
a. Stay at the bedside and reassure the patient.
b. Administer the ordered morphine sulfate IV.
c. Assess orientation and level of consciousness.
d. Use pulse oximetry to check the oxygen saturation.
ANS: D
Agitation in a patient who may have suffered inhalation injury might indicate hypoxia, 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 is also appropriate but not as essential as determining whether the patient is hypoxemic. Reassurance is not helpful to reduce agitation in a hypoxemic patient
A nurse is planning care for a client who has deep partial-thickness and full-thickness thermal burns over 40% of his total body surface and is in the acute phase of burn injury. Which of the following interventions should the nurse include in the plan?
•A. Initiate range-of-motion exercises
•B. Use clean technique to provide wound care
• C. Place the client on a low-protein diet
• D. Maintain the client on bed rest
Correct Answer: A. Initiate range-of-motion exercises
The nurse should begin performing active and passive range-of-motion exercises with the client to maintain mobility and prevent contractures.
Incorrect Answers:
A nurse in an emergency department is assessing a client who has extensive burns, including on her face. Which of the following assessments should the nurse perform first?
Correct Answer: B. Characteristics of the cough and sputum
The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse's priority assessment is the client's cough characteristics. A client who has burns to the face is at risk for pulmonary injury, and the development of a brassy cough can indicate an impending loss of airway.
Incorrect Answers:
A. The nurse should determine the percentage of the client's total body surface area that is burned to ensure proper care and provide an estimation of prognosis; however, there is another assessment that the nurse should perform first.
A client was moved from the ED to the burn unit and is the acute phase of burn management. The client has full-thickness burns to the anterior trunk, perineum, and sacral areas of the body. The nurse is creating a care plan for the client. Which is the most appropriate priority diagnosis at this time?
A. Risk for fluid volume overload
B. Risk for infection
C.impaired skin integrity
D. Impaired physical mobility
B
The three stages of burn management include emergent, acute, and rehabilitative. In the emergent phase, the client’s airway is priority and body fluids are replaced. In the acute phase, diuresis, wound healing, and complications are managed, and in the rehabilitative phase, psychosocial support and rehab is provided to get the client back to their optimal functioning.
A nurse is monitoring a client during the emergent phase of burn injury. Which findings indicate hypovolemic shock?
Select all that apply.
A. Decreased urine output
B. Tachycardia
C. Hypotension
D. Warm flushed skin
E. Increased hematocrit
F. Bradycardia
Answers: A, B, C, E
Burn shock causes:
↓ urine output
Tachycardia
Hypotension
Hemoconcentration → ↑ hematocrit