Burn NCLEX Questions with Answers and Rationales

1. A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is top priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake Correct Answer is C. Monitor Respiratory Status The priority action for the nurse when using airway, breathing, and circulation (ABC) approach to client care is to monitor the client’s respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation may become necessary to maintain a patient airway. Incorrect Answers A. The nurse should monitor the client’s intake and output because clients who have sustained major burns quickly dehydrate as a result of the fluid shift from the vascular system into the interstitial space; however, another action is the priority. B. Infection is serious health risk for clients who sustained major burns, and antibiotic therapy is probable; however, another action is the priority. C. Nutritional support is essential for clients who sustained major burns, although they might receive nutrients via IV or enteral tube initially; another action is the priority 1/56 2. 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 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: B. The nurse should use sterile technique to provide wound care for this client to reduce the risk of infection. C. The nurse should place the client on a high-protein, high-calorie diet to promote wound healing. D. The nurse should encourage the client to ambulate frequently to promote mobility and improve ventilation. 3. 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 visitor’s lounge?” 2/56 B. “I’ll see my friends when I get home” C. “My dad is coming to visit me. Can you fix my hair for me?” D. “I told my cousins I’m in protective custody.” Correct Answer: A. “May I go with my family to the lounge?” Incorrect Answers: B. This statement indicates that the client does not feel comfortable being seen by her peer group. Since peer interaction is important to an adolescent, the client's statement shows that she has not accepted the alterations in her face and hands. C. Asking for assistance with her appearance indicates the client has not yet accepted or adapted to her changed body image. Encouraging the client’s participation in self-care activities is a suggested nursing intervention because the independence fosters self-worth and a positive self-image. D. This statement indicates that the client does not feel comfortable being seen by her extended family. It demonstrates an attempt to escape from interpersonal contact and indicates that the client has not accepted the alterations in her face and hands. 4. 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? A. Hemoglobin 10 g/dL B. Sodium 132 mEq/L C. Albumin 3.6 g/dL D. Potassium 4.0 mEq/dL 3/56 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 Answer: 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. C. This laboratory finding is within the expected reference range. The nurse should anticipate a low albumin level during the resuscitation phase. D. This laboratory finding is within the expected reference range. The nurse should anticipate an elevated potassium level during the resuscitation phase. 5. 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? A. “I will be on a special shower table.” B. “The water temperature will be very cool to ease my pain.” C. “The nurse will use a firm-bristled brush to remove loose skin.” D. “The nurse will use scissors to open small blisters.” 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. 4/56 Incorrect Answers: B. The nurse should use warm water during the hydrotherapy treatment to help the client maintain adequate body temperature. C. The nurse should use soft washcloths or gauze to scrub and debride the wounds gently. D. The nurse should leave small blisters intact but open large blisters. 6. A nurse is assessing a client who sustained superficial partial-thickness and deep partialthickness burns 72 hr ago. Which of the following findings should the nurse report to the provider? A. Edema in the burned extremities B. Severe pain at the burn sites C. Urine output of 30 mL/hr D. Temperature of 39.1 degrees Celsius Correct Answer: D. Temperature of 39.1°C (102.4°F) An elevated temperature is an indication of infection, and the nurse should report this finding to the provider. Sepsis is a critical finding following a major burn injury. Initially, burn wounds are relatively pathogen-free. On approximately the third day following the injury, early colonization of the wound surface by gram-negative organisms changes to predominantly gram-positive opportunistic organisms. Incorrect Answers: A. Significant edema is expected when fluid shifts after a burn injury. B. Superficial partial-thickness and deep partial-thickness burns are painful throughout burn therapy. 5/56 C. A urinary output of 30 mL/hr is within the expected reference range. A decrease in urine output is expected with edema and fluid shifts around the fourth day following a major burn injury. 7. 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 Correct Answer: A. Bacterial growth Topical antimicrobial medications (particularly broad-spectrum antimicrobials) help prevent bacteria from entering the body when a client has an impairment of the protective covering of the skin, as with burns. It and the dressing create a protective barrier between bacteria and the exposed body tissues. This therapy helps prevent infection. Incorrect Answers: B. Topical antimicrobials do not prevent scarring or minimize permanent damage to the integumentary system. C. Topical antimicrobials do not reduce the size of the skin grafts the client requires. D. Opioids, not topical antimicrobials, reduce pain. 8. 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? A. Estimation of burn injury 6/56 B. Characteristics of the cough and sputum C. Extent of peripheral edema D. Amount of urine output 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. 7/56 C. The nurse should assess the extent of the client’s edema to determine the effects of the injury on the client’s cardiovascular status; however, there is another assessment that the nurse should perform first. D. The nurse should accurately monitor the client’s urine output to assess kidney function; however, there is another assessment that the nurse should perform first. 9. 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? A. Hyponatremia B. Leukopenia C. Hyperchloremia D. Elevated BUN Correct Answer: B. Leukopenia Transient leukopenia is an adverse effect of silver sulfadiazine. Incorrect Answers: A. Silver sulfadiazine does not cause an electrolyte imbalance. C. Hyperchloremia and other electrolyte imbalances can be adverse effects of mafenide acetate solution or cream. D. Impaired kidney function is an adverse effect of gentamicin. 10. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? A. Maintain the client in a prone position. 8/56 B. Elevate and immobilize the grafted extremity. C. Maintain the grafted extremity in a flat position. D. Keep the grafted extremity covered with a blanket. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized after surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the client in a prone position and covering the extremity with a blanket can disrupt the graft site. 11. Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? A. Glucose level of 99 mg/dL (5.65 mmol/L) B. Platelet level 300,000 mm3 (300 x 109/L) C. Magnesium level of 1.5 mEq/L (0.75 mmol/L) D. White Blood count of 3000 mm3 (3.0 x 109/L) Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified, and the medication is usually discontinued. The white blood cell count noted in option 4 is indicative of leukopenia. 9/56 The other laboratory values are not specific to this medication and are also within normal limits. 12. A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? A. Hyperventilation B. Elevated blood pressure C. Local rash at the burn site D. Local pain at the burn site Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury. 13. Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? A. "The medication is an antibacterial." B. "The medication will help heal the burn." C. "The medication should be applied directly to the wound." D. "The medication is likely to cause stinging every time it is applied." 10/56 Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gramnegative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied. 14. The camp nurse asks the children preparing to swim in the lake if they have applied sunscreen. The nurse reminds the children that chemical sunscreens are most effective when applied at which times? A. Immediately before swimming B. 5 minutes before exposure to the sun C. Immediately before exposure to the sun D. At least 30 minutes before exposure to the sun Rationale: Sunscreens are most effective when applied at least 30 minutes before exposure to the sun so that they can penetrate the skin. All sunscreens should be reapplied after swimming or sweating. 15. A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. A. Restrict fluids. B. Assess for airway patency. C. Administer oxygen as prescribed. D. Place a cooling blanket on the client. E. Elevate extremities if no fractures are present. 11/56 F. Prepare to give oral pain medication as prescribed. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained, and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm because the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury. 16. An adult client was burned in an explosion. The burn initially affected the client's entire face (anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire, and the client ran, causing subsequent burn injuries to the posterior surface of the head and the upper half of the posterior torso. Using the rule of nines, what would be the extent of the burn injury? A. 18% B. 24% C. 36% D. 48% 12/56 Rationale: According to the rule of nines, with the initial burn, the anterior half of the head equals 4.5%, the upper half of the anterior torso equals 9%, and the lower half of both arms equals 9%. The subsequent burn included the posterior half of the head, equaling 4.5%, and the upper half of the posterior torso, equaling 9%. This totals 36%. 17. The nurse is preparing to care for a burn client scheduled for an escharotomy procedure being performed for a third-degree circumferential arm burn. The nurse understands that which finding is the anticipated therapeutic outcome of the escharotomy? A. Return of distal pulses B. Brisk bleeding from the site C. Decreasing edema formation. D. Formation of granulation tissue Rationale: Escharotomies are performed to relieve the compartment syndrome that can occur when edema forms under nondistensible eschar in a circumferential third-degree burn. The escharotomy releases the tourniquet-like compression around the arm. Escharotomies are performed through avascular eschar to subcutaneous fat. Although bleeding may occur from the site, it is considered a complication rather than an anticipated therapeutic outcome. Usually, direct pressure with a bulky dressing and elevation controls the bleeding, but occasionally an artery is damaged and may require ligation. Escharotomy does not affect the formation of edema. Formation of granulation tissue is not the intent of an escharotomy. 13/56 18. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury? A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. 19. 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 which assessment would provide the most reliable indicator for determining the adequacy? A. Vital Signs 14/56 B. Urine output C. Mental status D. Peripheral pulses Rationale: Successful or adequate fluid resuscitation in the client is signaled by stable vital signs, adequate urine output, palpable peripheral pulses, and clear sensorium. However, the most reliable indicator for determining adequacy of fluid resuscitation, especially in a client with burns, is the urine output. For an adult, the hourly urine volume should be 30 to 50 mL. 20. The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which finding does the nurse expect to note during the resuscitation/emergent phase of the burn injury A. Decreased heart rate B. Increased urinary output C. Increased blood pressure D. Elevated hematocrit levels Rationale: The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48 to 72 hours following the injury. During the resuscitation/emergent phase, the hematocrit level increases to above normal because of hemoconcentration from the large fluid shifts. Hematocrit levels of 50% to 55% (0.50 to 0.55) are expected during the first 24 hours after injury, with return to normal by 36 hours after injury. Initially, blood is shunted away from the kidneys and 15/56 renal perfusion and glomerular filtration are decreased, resulting in low urine output. The burn client is prone to hypovolemia, and the body attempts to compensate by increased pulse rate and lowered blood pressure. Pulse rates are typically higher than normal, and the blood pressure is decreased as a result of the large fluid shifts. 21. The nurse is caring for a client following an autograft and grafting to a burn wound on the right knee. What would the nurse anticipate to be prescribed for the client? A. Out-of-bed activities B. Bathroom privileges C. Immobilization of the affected leg D. Placing the affected leg in a dependent position Rationale: Autografts placed over joints or on the lower extremities after surgery often are elevated and immobilized for 3 to 7 days. This period of immobilization allows the autograft time to adhere to the wound bed. Getting out of bed, going to the bathroom, and placing the grafted leg dependent would put stress on the grafted wound. 22. The emergency department nurse is caring for a client who has sustained chemical burns to the esophagus after ingestion of lye. The nurse reviews the primary health care provider's prescriptions and should plan to question which prescription? A. Gastric lavage B. Intravenous (IV) fluid therapy C. Nothing by mouth (NPO) status D. Preparation for laboratory studies 16/56 Rationale: The client who has sustained chemical burns to the esophagus is placed on NPO status, is given IV fluids for replacement and treatment of possible shock, and is prepared for esophagoscopy and barium swallow to determine the extent of damage. Laboratory studies also may be prescribed. A nasogastric tube may be inserted, but gastric lavage and emesis are avoided to prevent further erosion of the mucosa by the irritating substances that these treatments involve. 23. A client sustains a burn injury 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 percentage? Fill in the blank. 54% Rationale: According to the rule of nines, the right arm is equal to 9% and the left arm is equal to 9%. The right leg is equal to 18% and the left leg is equal to 18%. The anterior thorax is equal to 18% and the posterior thorax is equal to 18%. The head is equal to 9% and the perineum is equal to 1%. If the anterior thorax, the right leg, and the right and left arms were burned, according to the rule of nines, the total area involved would be 54%. 24. A client is admitted to the hospital emergency department after receiving a burn injury in a house fire. The skin on the client's trunk is tan, dry, and hard. It is edematous but not very painful. The nurse determines that this client's burn should be classified as which type? A. Superficial B. Full-thickness 17/56 C. Deep partial-thickness D. Partial-thickness superficial Rationale: Full-thickness burns involve the epidermis, the full dermis, and some of the subcutaneous fat layer. The burn appears to be a tan or fawn color, with skin that is hard, dry, and inelastic. Edema is severe, and the accumulated fluid compresses tissue underneath because of eschar formation. Some nerve endings have been damaged, and the area may be insensitive to touch, with little or no pain. 25. A client who is being evaluated for thermal burn injuries to the arms and legs complains of thirst and asks the nurse for a drink. Which action by the nurse is most appropriate? A. Allow the client to have full liquids. B. Give the client small glasses of clear liquids. C. Order the client a full meal tray with extra liquids. D. Keep the client on NPO (nothing by mouth) status. Rationale: The client should be maintained on NPO status because burn injuries frequently result in paralytic ileus. The client also should be told that fluids could cause vomiting because of the effect of the burn injury on gastrointestinal tract functioning. Mouth care should be given as appropriate to alleviate the sensation of thirst. 26. A client is seen in the ambulatory care clinic for a superficial burn to the arm. On assessing the skin at the burn injury, what will the nurse observe? A. White color B. Pink or red color 18/56 C. Weeping blisters D. Insensitivity to pain and cold Rationale: Superficial burns are pink or red without any blistering. The skin blanches to touch, may be edematous and painful, and heals on its own, usually within 1 week. A white color characterizes deep partial-thickness burns. Weeping blisters characterize partial-thickness superficial burns. Deep full-thickness burns are associated with insensitivity to pain and cold. 27. A client sustained a burn from cutaneous exposure to lye. At the site of injury, copious irrigation to the site was performed for 1 hour. On admission to the hospital emergency department, the nurse assesses the burn site. Which findings would indicate that the chemical burn process is continuing? A. Eschar B. Intact Blisters C. Liquefication necrosis D. Cherry-red, firm tissue Rationale: Alkalis, such as lye, cause a liquefaction necrosis, and exposure to fat results in formation of a soapy coagulum. Thick, leathery eschar forms with exposure to acids or heat. Intact blisters indicate a partial-thickness thermal injury. Cherry-red, firm tissue can occur as a result of thermal injury. 19/56 28. The nurse is caring for a client who was admitted to the burn unit after sustaining a burn injury covering 30% of the body. What is the most appropriate time frame for the emergent phase? A. The entire period of time during which rehabilitation occurs B. The period from the time the client is stable to the time when all burns are covered with skin C. The period from the time the burn was incurred to the time when the client is admitted to the hospital D. The period from the time the burn was incurred to the time when the client is considered physiologically stable Rationale: The emergent phase of burn care generally extends from the time the burn injury is incurred until the time when the client is considered physiologically stable. The acute phase lasts until all full-thickness burns are covered with skin. The rehabilitation period lasts approximately 5 years for an adult and includes reintegration into society. 29. The nurse is caring for a client with full-thickness circumferential burns of the entire trunk of the body who is on a mechanical ventilator. Which finding suggests that an escharotomy may be necessary? A. Pallor of all extremities B. Pulse oximetry reading of 93% C. Peripheral pulses are diminished D. High pressure alarm keeps sounding on the ventilator 20/56 Rationale: A client with a circumferential burn of the entire trunk likely will be on a ventilator because of the potential for breathing to be affected by this injury. The high pressure alarm will sound on the ventilator when there is any kind of obstruction. If the chest cannot expand due to restriction by eschar and increasing edema, this results in obstruction. 30. A client is diagnosed with a full-thickness burn. What should the nurse anticipate will be used for final coverage of the client's burn wound? Biobrane A. B. C. D. Autograft Xenograft Homograft Rationale: A full-thickness burn will require terminal coverage with an autograft–the client's own skin. Biobrane is porcine collagen bonded to a silicone membrane, which is temporary and lasts anywhere from 10 to 21 days. Homografts (cadaveric skin) and xenografts (pigskin) provide temporary coverage of the wound by acting as a dressing for up to 3 weeks before rejecting. 31. The nurse is planning care for a client who suffered a burn injury and has a negative selfimage related to keloid formation at the burn site. The keloid formation is indicative of which condition? 1. Nerve damage 21/56 2. 3. 4. Hypertrophy of collagen fibers Compromised circulation at the burn site Increase in subcutaneous tissue at the burn site Rationale: Keloids are visible as excessive scar formation and result from hypertrophy of collagen fibers. Nerves conduct sensory and motor impulses from the skin. The vasculature provides blood vessels with nourishment and assists in thermoregulation. Subcutaneous tissue provides for heat insulation, mechanical shock absorption, and caloric reserve. 32. A 60-kg client has sustained third-degree burns over 40% of the body. Using the Parkland (Baxter) formula, the minimum fluid requirements are which during the first 24 hours after the burn? 9600 mL of lactated Ringer's solution 1. 2. 3. 4. 4800 mL of 0.9% normal saline solution 2400 mL of 0.45% normal saline solution 1200 mL of 5% dextrose in water solution Rationale: The Parkland (Baxter) formula is 4 mL of lactated Ringer's solution × kg body weight × percent burn. The calculation is performed as follows: 4 mL × 60 kg × 40 = 9600 mL. 33. The nurse is evaluating fluid resuscitation attempts in the burn client. Which finding indicates adequate fluid resuscitation? 1. 2. 3. Disorientation to time only Heart rate of 95 beats/minute +1 palpable peripheral pulses 22/56 4. Urine output of 30 mL over the past 2 hours Rationale: When fluid resuscitation is adequate, the heart rate should be less than 120 beats/minute, as indicated in option 2. In addition, adequacy of fluid volume resuscitation can be evaluated by determining if urine output is at least 30 mL/hour, peripheral pulses are +2 or better, and the client is oriented to client, place, and time. 34. An adult client trapped in a burning house has suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, what percentage does the nurse determine the extent of the burn injury to be? Fill in the blank. 22.5% Rationale: According to the rule of nines, the posterior side of the head equals 4.5%, the back of both arms equals 9%, and the upper half of the posterior trunk equals 9%, totaling 22.5%. 35. A client is undergoing fluid replacement after 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/minute, and a urine output of 20 mL over the past hour. The nurse reports the findings to the primary health care provider (PHCP) and anticipates which prescription? 1. 2. 3. 4. Transfusing 1 unit of packed red blood cells Administering a diuretic to increase urine output Increasing the amount of intravenous (IV) lactated Ringer's solution administered per hour Changing the IV lactated Ringer's solution to one that contains 5% dextrose in water 23/56 Rationale: Fluid management during the first 24 hours following a burn injury generally includes the infusion of (usually) lactated Ringer's solution. Lactated Ringer's solution is an isotonic solution that contains electrolytes that will maintain fluid volume in the circulation. Fluid resuscitation is determined by urine output, and hourly urine output should be at least 30 mL/hour. The client's urine output is indicative of insufficient fluid resuscitation, which places the client at risk for inadequate perfusion of the brain, heart, kidneys, and other body organs. Therefore, the PHCP would prescribe an increase in the amount of IV lactated Ringer's solution administered per hour. There is nothing in the situation that calls for blood replacement, which is not used for fluid therapy for burn injuries. Administering a diuretic would not correct the problem because fluid replacement is needed. Diuretics promote the removal of the circulating volume, thereby further compromising the inadequate tissue perfusion. Intravenous 5% dextrose solution is isotonic before administered but is hypotonic once the dextrose is metabolized. Hypotonic solutions are not appropriate for fluid resuscitation of a client with significant burn injuries. 36. A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? Select all that apply. 1. 2. 3. 4. Restrict fluids. Assess for airway patency. Administer oxygen as prescribed. Place a cooling blanket on the client. 24/56 5. 6. Elevate extremities if no fractures are present. Prepare to give oral pain medication as prescribed. Rationale: The primary goal for a burn injury is to maintain a patent airway, administer intravenous (IV) fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and maintain a patent airway. The nurse then prepares to administer oxygen. Oxygen is necessary to perfuse vital tissues and organs. An IV line should be obtained and fluid resuscitation started. The extremities are elevated to assist in preventing shock and decrease fluid moving to the extremities, especially in the burn-injured upper extremities. The client is kept warm since the loss of skin integrity causes heat loss. The client is placed on NPO (nothing by mouth) status because of the altered gastrointestinal function that occurs as a result of a burn injury 37. A client arrives at the emergency department following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? 1. 2. 3. 4. 100% oxygen via an aerosol mask Oxygen via nasal cannula at 6 L/minute Oxygen via nasal cannula at 15 L/minute 100% oxygen via a tight-fitting, nonrebreather face mask Rationale: If an inhalation injury is suspected, administration of 100% oxygen via a tight-fitting nonrebreather face mask is prescribed until carboxyhemoglobin levels fall (usually below 25/56 15%). In inhalation injuries, the oropharynx is inspected for evidence of erythema, blisters, or ulcerations. The need for endotracheal intubation also is assessed. Administration of oxygen by aerosol mask and cannula are incorrect and would not provide the necessary oxygen supply needed for adequate tissue perfusion for the client with a likely inhalation injury. 38. The nurse is performing an assessment on a client admitted to the nursing unit who has sustained an extensive burn injury involving 45% of total body surface area. When planning for fluid resuscitation, the nurse should consider that fluid shifting to the interstitial spaces is greatest during which time period? 1. 2. 3. 4. Immediately after the injury Within 12 hours after the injury Between 18 and 24 hours after the injury Between 42 and 72 hours after the injury Rationale: The maximum amount of edema in a client with a burn injury is seen between 18 and 24 hours after the injury. With adequate fluid resuscitation, the transmembrane potential is restored to normal within 24 to 36 hours after the burn. The remaining options are incorrect. 39. The nursing educator has just completed a lecture to a group of nurses regarding care of the client with a burn injury. A major aspect of the lecture was care of the client at the scene of a fire. Which statement, if made by a nurse, indicates a need for further instruction? 26/56 "Flames should be doused with water." 1. 2. 3. 4. "The client should be maintained in a standing position." "Flames may be extinguished by rolling the client on the ground." "Flames may be smothered by the use of a blanket or another cover." Rationale: The client should be placed or maintained in a supine position; otherwise, flames may spread to other parts of the body, causing more extensive injury. Flame burns may be extinguished by rolling the client on the ground, smothering the flames with a blanket or other cover, or dousing the flames with water. 40. The 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, which is the immediate action? 1. 2. 3. 4. Cooling the injury with water Removing all clothing immediately Removing the tar from the burn injury Leaving any clothing that is saturated with tar in place Rationale: Scald burns and tar or asphalt burns are treated by immediate cooling with saline solution or water, if available, or immediate removal of the saturated clothing. Clothing that is burned into the skin is not removed because increased tissue damage and bleeding may result. No attempt is made to remove tar from the skin at the scene. 41. The 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 which is the first consideration in immediate care? 27/56 1. 2. 3. 4. Removing all clothing, including gloves, shoes, and any undergarments Determining the antidote for the chemical and placing the antidote on the burn site Leaving all clothing in place until the client is brought to the emergency department Lavaging the skin with water and avoiding brushing powdered chemicals off the clothing Rationale: In a chemical burn injury, the burning process continues as long as the chemical is in contact with the skin. All clothing, including gloves, shoes, and undergarments, is removed immediately, and water lavage is instituted before and during transport to the emergency department. Powdered chemicals are first brushed off the client before lavage is performed. 42. The nurse is performing an assessment on a client who sustained circumferential burns of both legs. Which assessment would be the initial priority in caring for this client? Assessing heart rate 1. 2. 3. 4. Assessing respiratory rate Assessing peripheral pulses Assessing blood pressure (BP) Rationale: The client who receives circumferential burns to the extremities is at risk for altered peripheral circulation. The priority assessment would be to assess for peripheral pulses to ensure that adequate circulation is present. Although the respiratory rate and BP also would be assessed, the priority with a 28/56 circumferential burn is assessment for the presence of peripheral pulses because the airway is not affected in this case. 43. The nurse has developed a nursing care plan for a client with a burn injury to implement during the emergent phase. Which priority intervention should the nurse include in the plan of care? Monitor vital signs every 4 hours. 1. 2. 3. 4. Monitor mental status every hour. Monitor intake and output every shift. Obtain and record weight every other day. Rationale: During the emergent phase after a burn injury, because of fluid volume deficits secondary to a burn injury, vital signs should be monitored every hour (every 4 hours is too infrequent) until the client is hemodynamically stable. The nurse should monitor the mental status of the client every hour for the first 48 hours. The weight should be obtained and recorded daily or twice daily, and intake and output measurements should be recorded on an hourly basis. 44. The nurse is developing a nursing care plan for a client with a circumferential burn injury of the right arm. What is the nurse's priority action? 1. 2. 3. 4. Monitor the radial pulse every hour. Keep the extremity in a dependent position. Document any changes that occur in the pulse. Place pressure dressings and wraps around the burn sites. 29/56 Rationale: In a client with ineffective tissue perfusion related to a circumferential burn injury, peripheral pulses should be assessed every hour for 72 hours. The affected extremities should be elevated, and the primary health care provider (PHCP) should be notified of any changes in pulses, capillary refill, or pain sensation. Pressure dressings and wraps should not be applied around the circumferential burn because they could cause a further alteration in peripheral circulation. 45. The nurse is providing care for a client who sustained burns over 30% of the body from a fire. On assessment, the nurse notes that the client is edematous in both burned and unburned body areas. The client's wife asks why her husband "looks so swollen." What is the nurse's best response? 1. 2. 3. 4. "Constricted blood vessels have caused a loss of protein in the blood." "Leaking blood vessels have led to increased protein amounts in the blood." "Leaking blood vessels have led to decreased protein amounts in the blood." "Constricted blood vessels have led to increased protein amounts in the blood Rationale: In extensive burn injuries (greater than 25% of total body surface area), the edema occurs in both burned and unburned areas as a result of the increase in capillary permeability and hypoproteinemia. Edema also may be caused by the volume and oncotic pressure effects of the large fluid resuscitation volumes required. 30/56 46. The nurse is reviewing the laboratory test results for a client admitted to the burn unit 3 hours after an explosion that occurred at a worksite. The client has a severe burn injury that covers 35% of the total body surface area (TBSA). The nurse is most likely to note which finding on the laboratory report? 1. 2. 3. 4. Hematocrit 60% (0.60) Serum albumin 4.8 g/dL (48 g/L) Serum sodium 144 mEq/L (144 mmol/L) White blood cell (WBC) count 9000 mm3 (9 × 109/L) Rationale: Extensive burns greater than 25% of the TBSA result in generalized body edema in both burned and unburned tissues and a decrease in circulating intravascular blood volume. Hematocrit levels are elevated in the first 24 hours after injury as a result of hemoconcentration from the loss of intravascular fluid. The normal hematocrit level ranges from 37% to 47% (0.37 to 0.47) (female) and 42% to 52% (0.42 to 0.52) (male). The remaining options identify normal laboratory values. 47. The nurse is caring for a client who sustained a thermal burn caused by the inhalation of steam 24 hours ago. The nurse determines that the priority nursing action is to assess which item? 1. 2. 3. 4. Pain level Lung sounds Ability to swallow Laboratory results 31/56 Rationale: The priority nursing action would be to assess lung sounds. Thermal burns to the lower airways can occur with the inhalation of steam or explosive gases or with the aspiration of scalding liquids. Thermal burns to the upper airways are more common and cause erythema and edema of the airways and mucosal blisters or ulcerations. The mucosal edema can lead to upper airway obstruction, particularly during the first 24 to 48 hours after a burn injury. 48. A client sustained a burn injury at 7:00 a.m. The client's spouse states that before the burn, the client's body weight was 198 lbs. The primary health care provider has estimated that the total body surface area (BSA) burned is 83%. Using the Parkland (Baxter) formula (4 mL × kilograms of body mass × percent total BSA), the nurse determines that the total amount of intravenous lactated Ringer's solution that the client will receive by 3 p.m. of the same day on which the burn occurred is which value? Fill in the blank. 14,940 mL Rationale: The Parkland (Baxter) formula for estimating fluid requirements is 4 mL × kilograms of body mass × percent total BSA. Half of this total is administered in the first 8 hours after the burn. First, convert pounds to kilograms by dividing 198 lbs by 2.2, which equals 90. Therefore, 4 × 90 × 83 = 29,880 mL, divided by 2 = 14,940 mL. 49. The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? 32/56 Urine pH of 6 1. 2. 3. 4. Urine that is pale yellow Urine output of 40 mL/hr Urine specific gravity of 1.032 Rationale: The client who is not adequately hydrated will have an elevated urine specific gravity. Normal values for urine specific gravity range from approximately 1.005 to 1.030. Pale yellow urine is a normal finding, as is a urine output of 40 mL/hr (minimum is 30 mL/hr). A urine pH of 6 is adequate (4.6 to 8.0 normal), and this value is not used in monitoring hydration status. 50. The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? 1. 2. 3. 4. Maintain the client in a prone position. Elevate and immobilize the grafted extremity. Maintain the grafted extremity in a flat position. Keep the grafted extremity covered with a blanket. Rationale: Autografts placed over joints or on lower extremities are elevated and immobilized following surgery for 3 to 7 days, depending on the surgeon's preference. This period of immobilization allows the autograft time to adhere and attach to the wound bed, and the elevation minimizes edema. Keeping the 33/56 client in a prone position and covering the extremity with a blanket can disrupt the graft site. 51. The nurse manager is observing a new nursing graduate caring for a burn client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which unsafe component of protective isolation technique? Using sterile sheets and linens 1. 2. 3. 4. Performing strict hand-washing technique Wearing gloves and a gown only when giving direct care to the client Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and plastic apron Rationale: In protective isolation, the nurse needs to protect the client at all times from any potential infectious contact. Thorough hand washing should be done before and after each contact with the burn-injured client. Sterile sheets and linens are used because of the client's high risk for infection. Protective garb, including gloves, cap, masks, shoe covers, gowns, and plastic apron, need to be worn when in the client's room and when directly caring for the client. 52. The nurse is supervising a nursing student who is delivering care to a client with a burn injury to the chest. Nitrofurazone is prescribed to be applied to the site of injury. The nurse should intervene if the student planned to implement which action to apply the medication? 1. Wash the burn site. 34/56 2. 3. 4. Apply the medication with a sterile gloved hand. Apply saline-soaked dressings over the medication. Apply 1/16-inch (1.5-mm) film directly to the burn sites. Rationale: Nitrofurazone is applied topically to the burn and has a broad spectrum of antibiotic activity. It is used in second- and third-degree burns when bacterial resistance to other agents is a potential problem. The burn site is washed before medication application. A film of 1/16 inch (1.5 mm) is applied directly to the burn using a sterile gloved hand. Saline-soaked dressings are not used with this medication because they will inactivate the medication's effect. In addition, wet dressings present the risk for infection, and infection is a primary concern with a client who is burned. 53. Silver sulfadiazine is prescribed for a client with a burn injury. Which laboratory finding requires the need for follow-up by the nurse? 1. 2. 3. 4. Glucose level of 99 mg/dL (5.5 mmol/L) Platelet level of 300,000 mm3 (300 × 109/L) Magnesium level of 1.5 mEq/L (0.75 mmol/L) White blood cell count of 3000 mm3 (3.0 × 109/L) Rationale: Silver sulfadiazine is used for the treatment of burn injuries. Adverse effects of this medication include rash and itching, blue-green or gray skin discoloration, leukopenia, and interstitial nephritis. The nurse should monitor a complete blood count, particularly the white blood cells, frequently for the client taking this medication. If leukopenia develops, the primary health care provider is notified and the medication is usually discontinued. The white blood cell count noted in 35/56 option 4 is indicative of leukopenia. The other laboratory values are not specific to this medication and are also within normal limits. 54. A burn client is receiving treatments of topical mafenide acetate to the site of injury. The nurse monitors the client, knowing that which finding indicates that a systemic effect has occurred? 1. 2. 3. 4. Hyperventilation Elevated blood pressure Local rash at the burn site Local pain at the burn site Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for signs of an acid-base imbalance (hyperventilation). If this occurs, the medication will probably be discontinued for 1 to 2 days. Options 3 and 4 describe local rather than systemic effects. An elevated blood pressure may be expected from the pain that occurs with a burn injury. 55. Silver sulfadiazine is prescribed for a client with a partial-thickness burn, and the nurse provides teaching about the medication. Which statement made by the client indicates a need for further teaching about the treatments? 1. 2. 3. 4. "The medication is an antibacterial." "The medication will help heal the burn." "The medication should be applied directly to the wound." "The medication is likely to cause stinging every time it is applied." 36/56 Rationale: Silver sulfadiazine is an antibacterial that has a broad spectrum of activity against gram-negative bacteria, gram-positive bacteria, and yeast. It is applied directly to the wound to assist in healing. It does not cause stinging when applied. 56. Mafenide acetate is prescribed for a client with a burn injury to the hand. Which should the nurse include in the instructions to the client regarding the use of this medication? 1. 2. 3. 4. If stinging occurs, discontinue the medication. Apply a thinner film than prescribed to the burn site if the medication stings. If local stinging and burning occur after the medication is applied, notify the health care provider. It is normal to experience local discomfort and stinging and burning after the medication is applied. Rationale: Mafenide acetate is bacteriostatic for both gram-negative and gram-positive organisms and is used to treat second- and third-degree burns to reduce the number of bacteria present in avascular tissues. The client should be informed that the medication will cause local discomfort, stinging, and burning and that this is normal. Therefore, options 1, 2, and 3 are incorrect. 57. A burn-injured client is receiving treatments of topical mafenide acetate to the site of injury. The nurse should monitor the client for which systemic effect that can occur from the use of this medication? 1. Acidosis 37/56 2. 3. 4. Alkalosis Hypotension Hypertension Rationale: Mafenide acetate is a carbonic anhydrase inhibitor and can suppress renal excretion of acid, thereby causing acidosis. Clients receiving this treatment should be monitored for acidosis, and if the acidosis becomes severe, the medication should be discontinued for 1 to 2 days. An elevated blood pressure may be expected in the client with pain. Alkalosis and hypotension are not associated with the use of this medication. 58. Collagenase is prescribed for a client with a severe burn to the hand. The home care nurse provides instructions to the client regarding the use of the medication. Which client statement indicates an accurate understanding of the use of this medication? 1. 2. 3. 4. "I will apply the ointment at bedtime and in the morning." "I will apply the ointment once a day and leave it open to the air." "I will apply the ointment twice a day and leave it open to the air." "I will apply the ointment once a day and cover it with a sterile dressing. Rationale: Collagenase is used to promote debridement of dermal lesions and severe burns. It is applied once daily and covered with a sterile dressing. The remaining options are incorrect. 38/56 59. A burn client has been having 1% silver sulfadiazine applied to burns twice a day for the past 3 days. Which laboratory abnormality indicates that the client is experiencing a side or adverse effect of this medication? 1. 2. 3. 4. Serum sodium of 120 mEq/L (120 mmol/L) Serum potassium of 3.0 mEq/L (3.0 mmol/L) White blood cell count of 3000 mm3 (3 × 109/L) pH of 7.30, PaCO2 of 32 mm Hg (32 mmHg), HCO3– of 19 mEq/L (19 mmol/L) Rationale: Transient leukopenia typically occurs after 2 to 3 days of treatment. Knowing this and knowing normal white blood cell values will direct you to option 3. Although options 1, 2, and 4 are abnormal findings, they are not associated with this medication. 60. Collagenase is prescribed for a client with a severe burn to the hand. The nurse is providing instructions to the client and spouse regarding wound treatment. Which should the nurse include in the instructions? Apply once a day and leave it open to the air. 1. 2. 3. 4. Apply twice a day and leave it open to the air. Apply twice a day and cover it with a sterile dressing. Apply once a day and cover it with a sterile dressing. Rationale: Collagenase is used in the treatment of dermal lesions and severe burns. Its action is to 39/56 debride the affected area. It is applied once daily and covered with a sterile dressing. Options 1, 2, and 3 are incorrect application procedures. 61. A client with a burn injury is applying mafenide acetate cream to the wound. The client calls the primary health care provider's (PHCP's) office and tells the nurse that the medication is uncomfortable and is causing a burning sensation. The nurse should instruct the client to take which action? Discontinue the medication. 1. 2. 3. 4. Continue with the treatment, as this is expected. Apply a thinner film than prescribed to the burn site. Come to the office to see the PHCP immediately. Rationale: Topical mafenide acetate is used to treat partial- and full-thickness burns. It is bacteriostatic for both gram-negative and gram-positive organisms present in avascular tissues. The client should be warned that the medication will cause local discomfort and burning. The nurse does not instruct a client to alter a medication prescription (options 1 and 3). It is not necessary that the client see the PHCP at this time. 62. An adult client with a burn injury just arrived at the emergency department. Place the nursing actions in the care of this client in order of priority. All options must be used. 1. 2. 3. 4. 5. 6. Assess for airway patency. Obtain vital signs. Administer oxygen as prescribed. Elevate the extremities. Keep the client warm. Initiate an intravenous (IV) line and begin fluid replacement as prescribed. 1 1 1 1 1 2 2 2 2 2 3 3 3 3 3 4 4 4 4 4 5 5 5 5 5 6 6 6 6 6 1 2 3 4 5 6 40/56 Rationale: The primary goals for a burn injury are to maintain a patent airway, administer IV fluids to prevent hypovolemic shock, and preserve vital organ functioning. Therefore, the priority actions are to assess for airway patency and to maintain a patent airway. The nurse then prepares to administer oxygen. The type of oxygen delivery system is prescribed by the primary health care provider. Oxygen is necessary to perfuse tissues and organs. Vital signs should be assessed so that a baseline is obtained, which is needed for comparison of subsequent vital signs once fluid resuscitation is initiated. The nurse then initiates an IV line and begins fluid replacement as prescribed. The extremities are elevated (if no obvious fractures are present) to assist in preventing shock. The client is kept warm (using sterile linens) and is placed on NPO status because of the altered gastrointestinal function that occurs as a result of the burn injury. A Foley catheter may be inserted so that the response to the fluid resuscitation can be carefully monitored. Once these actions are taken, the nurse performs a complete assessment, stays with the client, and monitors the client closely. In addition, tetanus toxoid may be prescribed for prophylaxis. 63. During the fluid accumulation phase of a major burn injury, fluids shift from the: A. intravascular space to the interstitial space. B. interstitial space to the intravascular space. C. intracellular space to the interstitial space. D. intravascular space to the intracellular space. 41/56 Answer: A. During the fluid accumulation phase, fluids shift from the intravascular space to the interstitial space. 64. Hypovolemia usually occurs during which major burn phase? A. Fluid remobilization B. Fluid accumulation C. Convalescent D. Acute Answer: B. Hypovolemia usually occurs during the fluid accumulation phase as fluid moves from the intravascular space to the interstitial space, a process known as third-space shift. 65. You insert an I.V. line and begin fluid resuscitation. The doctor wants you to use the Parkland formula. The patient is a 155-lb (70-kg) male and is estimated at having 50% of his total body surface area burned. What amount of lactated Ringer’s solution should you administer over the first 8 hours? A. 700 ml B. 7,000 ml C. 1,400 ml D. 6,000 ml Answer: B. The Parkland formula is 4 ml × the percentage of total body surface area burned × weight in kilograms. So, 4 ml × 50% × 70 kg = 14,000 ml or 14 L of lactated Ringer’s solution in the first 24 hours. Therefore, you would give 7,000 ml (or half) in the first 8 hours. 66. During the fluid remobilization phase of a patient with burn injuries, the nurse would expect to see signs of which electrolyte imbalance? 42/56 A. Hypokalemia B. Hyperkalemia C. Hypernatremia D. Hypovolemia Answer: A. Hypokalemia occurs in the fluid remobilization (diuresis) phase as potassium shifts from the extracellular fluid back into the cells. 67. A nurse in a provider’s office is assessing a client who has a severe sunburn. Which of the following classifications should the nurse use to document this burn? A. Superficial thickness B. Superficial partial thickness C. Deep partial thickness D. Full Thickness Answer: A. A sunburn is a superficial thickness burn. Superficial burns damage the top layer of the skin. 68. A nurse is caring for a client who has sustained burns over 35% of total body surface area. The client’s voice has become hoarse, a brassy cough has developed, and the client is drooling. The nurse should identify these findings as indications that the client has which of the following? A. Pulmonary edema B. Bacterial pneumonia C. Inhalation injury D. Carbon monoxide poisoning 43/56 Answer C. Wheezing and hoarseness indicate inhalation injury with impending loss of the airway. These require immediate reporting to the provider. 69. A nurse is assessing a client who sustained deep partial-thickness and full-thickness burn over 40% of the body 24 hours ago. Which of the following are findings are common during this phase? (Select all that apply) A. Temperature 36.1 degrees Celsius (97 degrees Fahrenheit) B. Bradycardia C. Hyperkalemia D. Hyponatremia E. Decreased hematocrit Answers (A, C, D). Decreased temperature can occur in the first few hours following a burn, because the body’s ability to regulate temperature compromised. Hyperkalemia occurs during the initial phase following a burn as a result of leakage of fluid from the intracellular space. 70. A nurse is preparing to administer fentanyl to a client who sustained deep partialthickness and full-thickness burns over 60% of the body 24 hours ago. The nurse should plan to use which of the following routes to administer the medication? A. Subcutaneous B. Oral C. Intravenous D. Transdermal Answer C. Use the IV route to administer pain medication for rapid absorption and fast pain relief during the resuscitation phase. 44/56 71. A nurse is planning care for an adult client who sustained severe burn injuries. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Limit visitors in the client’s room B. Encourage fresh vegetables in the diet C. Increase protein intake D. Instruct the client to consume 2,000 calories/day E. Restrict fresh flowers in the room Answers (A, C, E). Limit visitors and ensure ill individuals do not visit the client, to decrease the risk of infection. The client should increase protein consumption, which promotes would healing and prevents tissue breakdown. Flowers should not be the client’s room due to the bacteria they carry, which increases the risk for infection. 72. 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? A. Superficial partial thickness B. Deep partial thickness C. Full thickness D. First degree Answer is B. Deep-thickness burns are scalds and flash burns that injure the epidermis, upper dermis, and portions of deeper dermis. That causes pain, blistered, and mottled red skin, and edema. 45/56 73. 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? A. A 22-gauge intravenous line with normal saline infusing B. Wounds covered with moist sterile dressings C. No intravenous pain medication D. Adequate peripheral circulation to both feet ensured Answer is D. The client’s legs should have pedal pulses and be warn to the touch, and the client must be able to move the toes. 74. 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? A. Replace fluids and electrolytes B. Prevent contractures of extremities C. Monitor urine output hourly D. Prepare to assist with an escharotomy Answer is A. After airway, the most urgent need is preventing irreversible shock by replacing fluids and electrolytes 75. 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? A. The client complains of pain when the medication is administered B. The client’s potassium level is 3.9 mEq/L and sodium level is 137 mEq/L C. The client’s ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20 46/56 D. The client is able to perform active range-of-motion exercises. Answer is B. Sulfamylon is a strong carbonic anhydrase inhibitor that may reduce renal buffering and can cause metabolic acidosis. The ABGs indicate metabolic acidosis and therefore require immediate intervention. 76. The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, “What’s is xenograft?” Which statement by the nurse would be the best response? A. “The doctor will graft skin from your back to your leg.” B. “The skin from a donor will be used to cover your burn.” C. “The graft will come from an animal, probably a pig.” D. “I think you should ask your doctor about the graft.” Answer is C. A xenograft or heterograft consists of skin taken from animals, usually porcine 77. 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 of client problem has priority? A. High risk for infection B. Ineffective coping C. Impaired physical mobility D. Knowledge deficit Answer is A. Although this a potential problem, it is priority because the body’s protective barrier, the skin, has been compromised and there is an impaired immune response 47/56 78. The nurse writes the nursing diagnosis “impaired skin integrity related to open burn wounds.” Which intervention would be appropriate for this nursing diagnosis? A. Provide analgesia before pain becomes severe. B. Clean the client’s wounds, body, and hair daily. C. Screen visitors for respiratory infections D. Encourage visitors to bring plants and flowers. Answer is B. Daily cleaning reduces bacterial colonization. 79. 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) A. Perform meticulous hand hygiene. B. Use sterile gloves for wound care. C. Wear gown and mask during procedures. D. Change invasive lines once a week. E. Administer antibiotic as prescribed. Answers are A, B, C, E. Handwashing is the number-one intervention used to prevent infection, which is priority for the client with a burn. Aseptic techniques minimize risk of cross-contamination and spread of bacteria. Aseptic techniques minimize risk of crosscontamination and spread of bacteria. Antibiotic reduce bacteria 80. 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? A. The client is complaining of severe pain B. The client’s pulse oximeter reading is 95% C. The client has T 100.4⸰F, Pulse 100, Respirations 24, and BP 102/60 48/56 D. The client’s urinary output is 50 mL in two (2) hours Answer is D. Fluid and electrolytes 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. 81. 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? A. Encourage the client’s family to bring favorite foods. B. Provide a low-fat, low-cholesterol diet for the client. C. Monitor the client’s weight weekly in the same clothes. D. Make a referral to the hospital social worker. Answer is A. 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. 82. 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? A. Apply an ice pack to the right hand B. Place the hand in cool water C. Be sure to rupture any blister formation D. Go immediately to the doctor’s office Answer is B. Cool water gives immediate and striking relief from pain and limits local tissue edema and damage. 49/56 83. 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? A. Encourage the client to stay at home as much as possible. B. Discuss the importance of not relying on the family for needs. C. Tell the client to remember that changes in lifestyle take time. D. Instruct the client to discuss feelings only with the therapist Answer is C. 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. 84. The client is admitted to the burn unit and prescribed pantoprazole (Protonix), a proton pump inhibitor (PPI). Which statement best supports the scientific rationale for administering this medication to a client with a severe burn? A. This medication will help prevent a stress ulcer B. This medication will help prevent systemic infections C. This medication will provide continuous vasoconstriction D. This medication will stimulate new skin growth Answer is A. PPIs decrease gastric secretion and are prescribed for clients to prevent Curling’s stress ulcer. PPIs are ordered for most clients in the intensive care department, not just clients with burns. 85. 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. A. Estimate the amount of burned area using the rule of nines. B. Insert two (2) 18-gauge catheters and begin fluid replacement 50/56 C. Apply sterile saline dressings to the burned areas D. Determine the client’s airway status. E. Administer morphine sulfate, a narcotic analgesic, IV Answer is D, B, C, A, E. d. Airway is always the priority for any process in which the airway might be compromised. b. The nurse should start fluid resuscitation as soon as possible before the client’s blood pressure makes it more difficult to establish an IV route c. Covering the open burns will prevent further intrusion of bacteria a. Estimating the extent of the burned area should be done but does not have priority over airway, fluid replacement, and the prevention of infection e. Pain is priority but not over determining airway and fluid status and prevention of infection 86. A client is being seen in the dermatology clinic for a follow-up appointment for a seconddegree full-thickness burn. What are characteristics of second-degree burns? Select all that apply. A. Painful B. Blistered C. Mottled, pink red D. No edema 51/56 Answers is A, B, C. These burns appear as mottled pink, red, or waxy white areas with blisters and edema. The blisters resemble flat, dry tissue paper rather than the bullous blisters seen with superficial partial-thickness injury. 87. A client comes in with a sunburn. Which term best describes the sunburn? A. Second-degree burns B. First-degree burns C. Photosensitivity reaction D. Immune reaction to UV light Answer is B. First-degree burns (superficial partial-thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful. There usually is no blister formation. A mild sunburn is an example. 88. A client is admitted to the hospital with second-degree burns over 30% of the body. What is a characteristic of second-degree burns? A. They involve the dermis only B. They involve the dermis and the epidemis C. There is usually no blister formation D. They are dry 52/56 Answer is B. Second-degree burns involve the dermis and the epidermis. They are painful, moist, red, and blistered. Underneath the blisters is weeping, bright pink or red skin that is sensitive to temperature changes, air exposure, and touch. 89. A client is admitted to the hospital with first- and second-degree burns. Which assessment findings are associated with first-degree burns? Select all that apply. A. Full-thickness burns B. Painful C. Red or pink D. Wet Answer B and C. First-degree burns (superficial partial thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful. 90. A client has sustained serious first degree, second degree, and third degree burns in a fire. Which best describes this full-thickness burn and the burned area that involves subcutaneous tissue, muscle, and bone? A. Third-degree burn B. Second-and third degree burns C. Second-degree burn D. First-and second-degree burns 53/56 Answer is A. Third-degree full-thickness burns extend into the subcutaneous tissue and may involve muscle and bone. Thrombosed vessels can be seen under the burned skin, indicating that the underlying vasculature is involved. Third-degree burns vary in color from waxy white or yellow to tan, brown, deep red, or black. First-degree burns (superficial partial-thickness burns) involve only the outer layers of the epidermis. They are red or pink, dry, and painful. Second-degree burns involve both the epidermis and dermis. Second-degree partial-thickness burns involve the epidermis and various degrees of the dermis. 91. Which clinical manifestation would lead the health care provider to diagnose the sunburn as severe? A. Skin is red and warm to touch B. Some peeling and itching occur several days after the initial burn C. There is blistering of the skin and associated fever and chills D. There is a pruritic rash over the sunburned skin area. Answer is C. Sunburn ranges from mild to severe. Mild sunburn consists of various degrees of skin redness. The burn continues to develop for 24 to 72 hours, occasionally followed by peeling skin in 3 to 8 days. Some peeling and itching may continue for several weeks. Inflammation, blistering, weakness, chills, fever, malaise, and pain often accompany severe forms of sunburn. 54/56 92. An adult man has been brought to the emergency department with severe electrical burns. Which assessment finding leads the providers to suspect the brain has been damaged with this burn? A. Infection with drainage on the ears B. Confusion, memory loss, and lethargy C. Acute pain, tachycardia, light sensitivity D. Impaired hearing, double vision, and wheezing Answer is C. The most immediate threat to this client is hemodynamic instability. If the brain or spine is directly injured from the burn, the client will have neurologic signs/symptoms like confusion, memory loss, insomnia, lethargy, and combativeness. Infection would develop later if at all. Pain control is essential, but inadequate pain control does not pose a direct threat to survival. Impaired hearing and double-vision may occur if the client has had a head injury but wheezing is usually caused by smoke inhalation. 93. Your patient has partial- and full-thickness burn injuries to his anterior chest, anterior abdomen, and entire right arm. Using the Rule of Nines, the percentage of total BSA involved can be estimated at: A. 18%. B. 27%. C. 45%. D. 50%. 55/56 B. The anterior chest and abdomen constitute 18% of the BSA, and the entire right arm is 9%, for a total of 27%. 56/56