Classification & Severity
Healing
NCLEX style questions
Nursing Care
Pharmacology
100
Classify this burn
What is a first degree (superficial) burn?
rational: superficial burns involve only the first layer of skin or the epidermis (hence called first-degree injury) and typically heal in 3 to 5 days without treatment. Superficial burn injuries are not included in burn size (extent of injury) calculations used for fluid resuscitation requirements because they only cause erythema and do not involve the dermis. (page 557)
100
A 23-year-old male client who has had a full-thickness burn is being discharged from the hospital. Which information is most important for the nurse to provide prior to discharge?
A. How to maintain home smoke detectors
B. Joining a community reintegration program
C. Learning to perform dressing change
D. Options available for scar removal
C. Learning to perform dressing changes
Rationale:
Correct Answer: C. Learning to perform dressing changes
Teaching the patient and his family to perform dressing changes is critical for the goal of progression towards independence. Proper management of burn injury through proper dressing changes helps prevent wound deterioration. Encouragement of the patient and his family members in participating in dressing changes and wound care helps prepare for the patient’s eventual discharge and home care needs. All other choices (below) are important during the rehabilitation stage but dressing changes is a priority.
100
Route for administration of opioids for pain control during a burn.
What is an IV route.
Rationale: IV opioid administration is the route of choice.
200
The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize this injury?
what is a full-thickness burn?
rationale: The characteristics of the wounds 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. The burn is leathery and dry. There is minimal to no pain because of decreased sensation. Full-thickness burns require skin grafting.
200
A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; respiratory rate, 25/min. He is pale in color and it is difficult to find pedal pulses. Which action will the nurse take first?
A. Start intravenous fluids.
B. Check the pulses using a Doppler device.
C. Obtain a complete blood count (CBC).
D. Obtain an electrocardiogram (ECG).
A. Start intravenous fluids
Rationale:
Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Administration of fluids can treat this problem. For burns classified as severe (> 20% TBSA), fluid resuscitation should be initiated to maintain urine output > 0.5 mL/kg/hour.
200
To maintain a positive nitrogen balance in a major burn, the patient must:
a. eat a high-protein, low-fat, high-carbohydrate diet
b. increase normal caloric intake by about three times
c. eat at least 1500 calories/day in small, frequent meals
d. eat rice and whole wheat for the chemical effect on nitrogen balance.
what is a. eat a high-protein, low-fat, high-carbohydrate diet?
rationale: If the patient is able to tolerate an oral diet, institute a high-calorie, high-protein diet with supplements and perform daily calorie counts to monitor dietary intake. (page 581)
300
Layer of skin that is effected by a partial thickness burn.
what is dermal (or second) layer
rationale:
Partial-thickness burns involve injury to the second skin layer or dermal layer (hence a second-degree injury) (page 557)
300
On assessment, the nurse notes that the client has burns inside the mouth and is wheezing. Several hours later, the wheezing is no longer heard. What is the nurse’s next action?
A. Documenting the findings
B. Loosening any dressings on the chest
C. Raising the head of the bed
D. Preparing for intubation
D. Preparing for intubation
Rationale: Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose the 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. The swelling usually precludes intubation.
400
classify this burn
what is a full-thickness (4th degree burn)
rationale: table 21.3
400
A 32-year-old client, who is on an anticoagulant medication due to a history of deep vein thrombosis, arrives at the emergency department after accidentally spilling a pot of boiling water mixed with hot oil on their right arm while attempting to deep-fry food at home. The client is in significant pain and reports that the burn occurred approximately 30 minutes ago. Upon assessment, the nurse observes a large burned area on the client’s right arm with a mix of pink and mottled red areas, blisters, and signs of active bleeding from the blistered areas. The burned area is very painful to touch and the client is visibly anxious.
Based on the assessment findings and the client’s medical history, how will the nurse categorize this burn injury?
A. Full-thickness
B. Partial-thickness superficial
C. Partial-thickness deep
D. Full-thickness deep
C. Partial thickness deep
Rationale: Deep partial-thickness burns are pink or red in color, swollen, painful, with blisters that may ooze a clear fluid. Deep partial-thickness (second-degree) involves the deeper dermis. Healing occurs in 3 to 8 weeks with scarring present.
500
The palmar surface, including the fingers, of the patient’s hand represents what percent of his or her total body surface area?
what is 1%?
rationale: The nurse can use the size of the patient’s palm (including fingers) to calculate injury extent of irregular or scattered small burns; the patient’s palm represents 1% of the TBSA (page 557)
500
The healing time for a full thickness burn.
What is does not heal and requires a skin graft, amputation or extensive debridement.
Rationale: a full-thickness injury (i.e., third-degree injury; sometimes called fourth-degree when muscle and bone are involved). This creates a thick, leathery, nonelastic, coagulated layer of dead, necrotic tissue called eschar. The nerves are destroyed, resulting in a painless wound. These injuries always require skin grafting for permanent wound closure. (page 557)
500
A 35-year-old male client was admitted due to severe burns around his right hip. Which position is most important to use to maintain the maximum function of this joint?
A. Hip maintained in 30-degree flexion
B. Hip at zero flexion with leg flat
C. Knee flexed at 30-degree angle
D. Leg abducted with a foam wedge
B. Hip at zero flexion with leg flat
Rationale: The 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 in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.