Burns (Exam Mode) By Rnpedia

1. The burned client's family ask at what point the client will no longer be at increased risk for infection. What is the nurse's best response?

“When fluid remobilization has started.”

“When the burn wounds are closed.”

“When IV fluids are discontinued.”

“When body weight is normal.”

Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.

DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

Intact skin is a major barrier to infection and other disruptions in homeostasis. No matter how much time has passed since the burn injury, the client remains at great risk for infection as long as any area of skin is open.

DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

2. Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate?

The client is able to talk.

The client is alert and oriented.

The client's oxygen saturation is 97%.

The client's chest movements are uninhibited

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

3. Which information obtained by assessment ensures that the client's respiratory efforts are currently adequate?

The client is able to talk.

The client is alert and oriented.

The client's oxygen saturation is 97%.

The client's chest movements are uninhibited

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

Clients may have ineffective respiratory efforts and gas exchange even though they are able to talk, have good respiratory movement, and are alert. The best indicator for respiratory effectiveness is the maintenance of oxygen saturation within the normal range.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

4. Which clinical manifestation indicates that the burned client is moving into the fluid remobilization phase of recovery?

Increased urine output, decreased urine specific gravity

Increased peripheral edema, decreased blood pressure

Decreased peripheral pulses, slow capillary refill

Decreased serum sodium level, increased hematocrit

The “fluid remobilization” phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

The “fluid remobilization” phase improves renal blood flow, increasing diuresis and restoring fluid and electrolyte levels. The increased water content of the urine reduces its specific gravity.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

5. All of the following laboratory test results on a burned client's blood are present during the emergent phase. Which result should the nurse report to the physician immediately?

Serum sodium elevated to 131 mmol/L (mEq/L)

Serum potassium 7.5 mmol/L (mEq/L)

Arterial pH is 7.32

Hematocrit is 52%

All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

All these findings are abnormal; however, only the serum potassium level is changed to the degree that serious, life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment/Analysis
MSC: Client Needs Category: Safe, Effective Care Environment;

6. Which vitamin deficiency is most likely to be a long-term consequence of a full-thickness burn injury?

Vitamin A

Vitamin B

Vitamin C

Vitamin D

Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in fullthickness burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Health Promotion and Maintenance

Explanation

Skin exposed to sunlight activates vitamin D. Partial-thickness burns reduce the activation of vitamin D. Activation of vitamin D is lost completely in fullthickness burns.
DIF: Cognitive Level: Knowledge TOP: Nursing Process Step: N/A
MSC: Client Needs Category: Health Promotion and Maintenance

7. The burned client is ordered to receive intravenous cimetidine, an H2 histamine blocking agent, during the emergent phase. When the client's family asks why this drug is being given, what is the nurse's best response?

“To increase the urine output and prevent kidney damage.”

“To stimulate intestinal movement and prevent abdominal bloating.”

“To decrease hydrochloric acid production in the stomach and prevent ulcers.”

“To inhibit loss of fluid from the circulatory system and prevent hypovolemic shock.”

Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. Cimetidine inhibits the production and release of hydrochloric acid.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

8. The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse's best first action?

Administer oxygen.

Loosen the dressing.

Notify the emergency team.

Document the observation as the only action.

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client's respiratory status.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

9. Which statement by the client indicates correct understanding of rehabilitation after burn injury?

“I will never be fully recovered from the burn.”

“I am considered fully recovered when all the wounds are closed.”

“I will be fully recovered when I am able to perform all the activities I did before my injury.”

“I will be fully recovered when I achieve the highest possible level of functioning that I can.”

Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity

Explanation

Although a return to preburn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity

10. The burned client on admission is drooling and having difficulty swallowing. What is the nurse's best first action?

Assess level of consciousness and pupillary reactions.

Ask the client at what time food or liquid was last consumed.

Auscultate breath sounds over the trachea and mainstem bronchi.

Measure abdominal girth and auscultate bowel sounds in all four quadrants.

Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Difficulty swallowing and drooling are indications of oropharyngeal edema and can precede pulmonary failure. The client’s airway is in severe jeopardy and intubation is highly likely to be needed shortly.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

11. Ten hours after the client with 50% burns is admitted, her blood glucose level is 90 mg/dL. What is the nurse's best action?

Notify the emergency team.

Document the finding as the only action.

Ask the client if anyone in her family has diabetes mellitus.

Slow the intravenous infusion of dextrose 5% in Ringer's lactate.

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

12. Which intervention is most important for the nurse to use to prevent infection by cross-contamination in the client who has open burn wounds?

Handwashing on entering the client's room

Encouraging the client to cough and deep breathe

Administering the prescribed tetanus toxoid vaccine

Changing gloves between cleansing different burn areas

Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only handwashing can prevent crosscontamination.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Cross-contamination occurs when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed above can help reduce the risk for infection, only handwashing can prevent crosscontamination.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

13. In assessing the client's potential for an inhalation injury as a result of a flame burn, what is the most important question to ask the client on admission?

“Are you a smoker?”

“When was your last chest x-ray?”

“Have you ever had asthma or any other lung problem?”

“In what exact place or space were you when you were burned?”

The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

The risk for inhalation injury is greatest when flame burns occur indoors in small, poorly ventilated rooms. although smoking increases the risk for some problems, it does not predispose the client for an inhalation injury.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

14. The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

Seasonal asthma

Hepatitis B 10 years ago

Myocardial infarction 1 year ago

Kidney stones within the last 6 month

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and
pulmonary edema during fluid resuscitation.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and
pulmonary edema during fluid resuscitation.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

15. On admission to the emergency department the burned client's blood pressure is 90/60, with an apical pulse rate of 122. These findings are an expected result of what thermal injury–related response?

Fluid shift

Intense pain

Hemorrhage

Carbon monoxide poisoning

Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care Environment;

Explanation

Intense pain and carbon monoxide poisoning increase blood pressure. Hemorrhage is unusual in a burn injury. The physiologic effect of histamine release in injured tissues is a loss of vascular volume to the interstitial space, with a resulting decrease in blood pressure.

DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care Environment;

16. The newly admitted client has a large burned area on the right arm. The burned area appears red, has blisters, and is very painful. How should this injury be categorized?

Superficial

Partial-thickness superficial

Partial-thickness deep

Full thickness

The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red; blisters; pain present and high).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

The characteristics of the wound meet the criteria for a superficial partialthickness injury (color that is pink or red; blisters; pain present and high).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

17. Which statement made by the client with facial burns who has been prescribed to wear a facial mask pressure garment indicates correct understanding of the purpose of this treatment?

“After this treatment, my ears will not stick out.”

“The mask will help protect my skin from sun damage.”

“Using this mask will prevent scars from being permanent.”

“My facial scars should be less severe with the use of this mask.”

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not change the angle of ear attachment to the head.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and Maintenance

Explanation

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not change the angle of ear attachment to the head.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Psychosocial Integrity/Health Promotion and Maintenance

18. Which client factors should alert the nurse to potential increased complications with a burn injury?

The client is a 26-year-old male.

The client has had a burn injury in the past.

The burned areas include the hands and perineum.

The burn took place in an open field and ignited the client's clothing.

Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care Environment;

Explanation

Burns of the perineum increase the risk for sepsis. Burns of the hands require special attention to ensure the best functional outcome.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Physiological Integrity/Safe, Effective Care Environment;

19. What clinical manifestation indicates that an escharotomy is needed on a circumferential extremity burn?

The burn is full thickness rather than partial thickness.

The client is unable to fully pronate and supinate the extremity.

Capillary refill is slow in the digits and the distal pulse is absent.

The client cannot distinguish the sensation of sharp versus dull in the extremity.

Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Circumferential eschar can act as a tourniquet when edema forms from the fluid shift, increasing tissue pressure and preventing blood flow to the distal extremities and increasing the risk for tissue necrosis. This problem is an emergency and, without intervention, can lead to loss of the distal limb. This problem can be reduced or corrected with an escharotomy.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;

20. What additional laboratory test should be performed on any African American client who sustains a serious burn injury?

Total protein

Tissue type antigens

Prostate specific antigen

Hemoglobin S electrophoresis

Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client’s sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

Sickle cell disease and sickle cell trait are more common among African Americans. Although clients with sickle cell disease usually know their status, the client with sickle cell trait may not. The fluid, circulatory, and respiratory alterations that occur in the emergent phase of a burn injury could result in decreased tissue perfusion that is sufficient to cause sickling of cells, even in a person who only has the trait. Determining the client’s sickle cell status by checking the percentage of hemoglobin S is essential for any African American client who has a burn injury.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

21. What statement by the client indicates the need for further discussion regarding the outcome of skin grafting (allografting) procedures?

“For the first few days after surgery, the donor sites will be painful.”

“Because the graft is my own skin, there is no chance it won't 'take'.”

“I will have some scarring in the area when the skin is removed for grafting.”

“Once all grafting is completed, my risk for infection is the same as it was before I was burned.”

Factors other than tissue type, such as circulation and infection, influence whether and how well a graft “takes.” The client should be prepared for the possibility that not all grafting procedures will be successful.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

Explanation

Factors other than tissue type, such as circulation and infection, influence whether and how well a graft “takes.” The client should be prepared for the possibility that not all grafting procedures will be successful.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Health Promotion and Maintenance/Psychosocial Integrity

22. Which type of fluid should the nurse expect to prepare and administer as fluid resuscitation during the emergent phase of burn recovery?

Colloids

Crystalloids

Fresh-frozen plasma

Packed red blood cells

Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer’s lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Although not universally true, most fluid resuscitation for burn injuries starts with crystalloid solutions, such as normal saline and Ringer’s lactate. The burn client rarely requires blood during the emergent phase unless the burn is complicated by another injury that involved hemorrhage. Colloids and plasma are not generally used during the fluid shift phase because these large particles pass through the leaky capillaries into the interstitial fluid, where they increase the osmotic pressure. Increased osmotic pressure in the interstitial fluid can worsen the capillary leak syndrome and make maintaining the circulating fluid volume even more difficult.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

23. The client has experienced an electrical injury, with the entrance site on the left hand and the exit site on the left foot. What are the priority assessment data to obtain from this client on admission?

Airway patency

Heart rate and rhythm

Orientation to time, place, and person

Current range of motion in all extremities

The airway is not at any particular risk with this injury. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

The airway is not at any particular risk with this injury. Electric current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate, rhythm, and ECG changes.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

24. The client who experienced an inhalation injury 6 hours ago has been wheezing. When the client is assessed, wheezes are no longer heard. What is the nurse's best action?

Raise the head of the bed.

Notify the emergency team.

Loosen the dressings on the chest.

Document the findings as the only action.

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose 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 and the swelling usually precludes intubation.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose 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 and the swelling usually precludes intubation.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

25. What clinical manifestation should alert the nurse to possible carbon monoxide poisoning in a client who experienced a burn injury during a house fire?

Pulse oximetry reading of 80%

Expiratory stridor and nasal flaring

Cherry red color to the mucous membranes

Presence of carbonaceous particles in the sputum

The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a “cherry red” color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

The saturation of hemoglobin molecules with carbon monoxide and the subsequent vasodilation induces a “cherry red” color of the mucous membranes in these clients. The other manifestations are associated with inhalation injury, but not specifically carbon monoxide poisoning.
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

26. What is the priority nursing diagnosis for a client in the rehabilitative phase of recovery from a burn injury?

Acute Pain

Impaired Adjustment

Deficient Diversional Activity

Imbalanced Nutrition: Less than Body Requirements

Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Psychosocial Integrity

Explanation

Recovery from a burn injury requires a lot of work on the part of the client and significant others. Seldom is the client restored to the preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous life-changing alterations that must be made or overcome by the client. By the rehabilitation phase, acute pain from the injury or its treatment is no longer a problem.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Psychosocial Integrity

27. When should ambulation be initiated in the client who has sustained a major burn?

When all full-thickness areas have been closed with skin grafts

When the client's temperature has remained normal for 24 hours

As soon as possible after wound debridement is complete

As soon as possible after resolution of the fluid shift

Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.

DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

Regular, progressive ambulation is initiated for all burn clients who do not have contraindicating concomitant injuries as soon as the fluid shift resolves. Clients can be ambulated with extensive dressings, open wounds, and nearly any type of attached lines, tubing, and other equipment.

DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

28. Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

Changing gloves between wound care on different parts of the client's body.

Avoiding sharing equipment such as blood pressure cuffs between clients.

Using the closed method of burn wound management.

Using proper and consistent handwashing.

Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client’s body can prevent autocontamination.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

Autocontamination is the transfer of microorganisms from one area to another area of the same client's body, causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection, only changing gloves between carrying out wound care on difference parts of the client’s body can prevent autocontamination.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

29. The client has a deep partial-thickness injury to the posterior neck. Which intervention is most important to use during the acute phase to prevent contractures associated with this injury?

Place a towel roll under the client's neck or shoulder.

Keep the client in a supine position without the use of pillows.

Have the client turn the head from side to side 90 degrees every hour while awake.

Keep the client in a semi-Fowler’s position and actively raise the arms above the head every hour while awake.

The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care Environment;

Explanation

The function that would be disrupted by a contracture to the posterior neck is flexion. Moving the head from side to side prevents such a loss of flexion.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Health Promotion and Maintenance/Safe, Effective Care Environment;

30. The client has severe burns around the right hip. Which position is most important to be emphasized by the nurse that the client maintain to retain maximum function of this joint?

Hip maintained in 30-degree flexion, no knee flexion

Hip flexed 90 degrees and knee flexed 90 degrees

Hip, knee, and ankle all at maximum flexion

Hip at zero flexion with leg flat

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 at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

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 at a time in this position, he or she should be in this position (in bed or standing) more of the time than with the hip in any degree of flexion.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

31. The newly admitted client has burns on both legs. The burned areas appear white and leather-like. No blisters or bleeding are present, and the client states that he or she has little pain. How should this injury be categorized?

Superficial

Partial-thickness superficial

Partial-thickness deep

Full thickness

The characteristics of the wound 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).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

The characteristics of the wound 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).
DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

32. In reviewing the burned client's laboratory report of white blood cell count with differential, all the following results are listed. Which laboratory finding indicates the possibility of sepsis?

The total white blood cell count is 9000/mm3.

The lymphocytes outnumber the basophils.

The “bands” outnumber the “segs.”

The monocyte count is 1,800/mm3.

Normally, the mature segmented neutrophils (“segs”) are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature “band” neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

Explanation

Normally, the mature segmented neutrophils (“segs”) are the major population of circulating leukocytes, constituting 55% to 70% of the total white blood count. Fewer than 3% to 5% of the circulating white blood cells should be the less mature “band” neutrophils. A left shift occurs when the bone marrow releases more immature neutrophils than mature neutrophils. Such a shift indicates severe infection or sepsis, in which the client’s immune system cannot keep pace with the infectious process.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment/Health Promotion and Maintenance;

33. At what point after a burn injury should the nurse be most alert for the complication of hypokalemia?

Immediately following the injury

During the fluid shift

During fluid remobilization

During the late acute phase

Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Hypokalemia is most likely to occur during the fluid remobilization period as a result of dilution, potassium movement back into the cells, and increased potassium excreted into the urine with the greatly increased urine output.
DIF: Cognitive Level: Comprehension TOP: Nursing Process Step: Assessment
MSC: Client Needs Category: Safe, Effective Care Environment;

34. The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal temperature, is hypotensive, and has diarrhea. What is the nurse's best action?

Nothing, because the findings are normal for clients during the acute phase of recovery.

Increase the temperature in the room and increase the IV infusion rate.

Assess the client’s airway and oxygen saturation.

Notify the burn emergency team.

These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

35. Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. What is the nurse's best action?

Reposition the client onto the right side.

Document the finding as the only action.

Notify the emergency team.

Increase the IV flow rate.

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

Explanation

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response, and it is not the highest priority of care at this time.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment/Physiological Integrity;

36. During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

Increased wound pain 30 to 40 minutes after drug application

Presence of small, pale pink bumps in the wound beds

Decreased white blood cell count

Increased serum creatinine level

Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Gentamicin does not stimulate pain in the wound. The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Evaluation
MSC: Client Needs Category: Safe, Effective Care Environment;

37. The burned client newly arrived from an accident scene is prescribed to receive 4 mg of morphine sulfate by IV push. What is the most important reason to administer the opioid analgesic to this client by the intravenous route?

The medication will be effective more quickly than if given intramuscularly.

It is less likely to interfere with the client’s breathing and oxygenation.

The danger of an overdose during fluid remobilization is reduced.

The client delayed gastric emptying.

Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

Although providing some pain relief has a high priority, and giving the drug by the IV route instead of IM, SC, or orally does increase the rate of effect, the most important reason is to prevent an overdose from accumulation of drug in the interstitial space during the fluid shift of the emergent phase. When edema is present, cumulative doses are rapidly absorbed when the fluid shift is resolving. This delayed absorption can result in lethal blood levels of analgesics.
DIF: Cognitive Level: Comprehension
TOP: Nursing Process Step: Implementation/Intervention
MSC: Client Needs Category: Safe, Effective Care Environment;

38. What is the priority nursing diagnosis during the first 24 hours for a client with full-thickness chemical burns on the anterior neck, chest, and all surfaces of the left arm?

Risk for Ineffective Breathing Pattern

Decreased Tissue Perfusion

Risk for Disuse Syndrome

Disturbed Body Image

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care Environment;

Explanation

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury.

DIF: Cognitive Level: Application or higher
TOP: Nursing Process Step: Analysis
MSC: Client Needs Category: Safe, Effective Care Environment;