Burn Injury Nursing Management | NCLEX Quiz

1. Three days after a burn injury. the client develops a temperature of 100° F. white blood cell count of 15.000/mm3. and a white. foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?

Acute phase of the injury

Autodigestion of collagen

Granulation of burned tissue

Wound infection

Color change. purulent. foul-smelling drainage. increased white blood cell count. and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

Explanation

Color change. purulent. foul-smelling drainage. increased white blood cell count. and fever could all indicate infection. These symptoms will not be seen in the acute phase of the injury. Autodigestion of collagen and granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge.

2. Which assessment finding assists the nurse in confirming inhalation injury?

Brassy cough

Decreased blood pressure

Nausea

Headache

Brassy cough and wheezing are some signs seen with inhalation injury. All the other symptoms are seen with carbon monoxide poisoning.

Explanation

Brassy cough and wheezing are some signs seen with inhalation injury. All the other symptoms are seen with carbon monoxide poisoning.

3. What intervention will the nurse implement to reduce a client's pain after a burn injury?

Administering morphine 4 mg intravenously.

Administering hydromorphone (Dilaudid) 4 mg intramuscularly.

Applying ice to the burned area

Avoiding tactile stimulation

Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering. the room must be kept warm and heat should be applied.

Explanation

Drug therapy for pain management requires opioid and nonopioid analgesics. The IV route is used because of problems with absorption from the muscle and stomach. Tactile stimulation can be used for pain management. For the client to avoid shivering. the room must be kept warm and heat should be applied.

4. What statement indicates the client needs further education regarding the skin grafting (allografting)?

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

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

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

“I am still at risk for infection after the procedure.”

Factors other than tissue type. such as circulation and infection. influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. The donor sites will be painful after the surgery. there can be scarring in the area where skin is removed for grafting. and the client is still at risk for infection.

Explanation

Factors other than tissue type. such as circulation and infection. influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. The donor sites will be painful after the surgery. there can be scarring in the area where skin is removed for grafting. and the client is still at risk for infection.

5. The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

Administer the prescribed tetanus toxoid vaccine.

Assess wounds for signs of infection.

Encourage the client to cough and breathe deeply.

Wash hands on entering the client’s room.

Infection can occur when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed can help reduce the risk for infection. hand washing is the most effective technique for preventing infection transmission.

Explanation

Infection can occur when microorganisms from another person or the environment are transferred to the client. Although all the interventions listed can help reduce the risk for infection. hand washing is the most effective technique for preventing infection transmission.

6. Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury?

“It is normal to feel depressed.”

“I will be able to go back to work immediately.”

“I will not feel anger about my situation.”

“Once I get home. things will be normal.”

During the recovery period. and for some time after discharge from the hospital. clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Feelings of grief. loss. anxiety. anger. fear. and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

Explanation

During the recovery period. and for some time after discharge from the hospital. clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems. Feelings of grief. loss. anxiety. anger. fear. and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

7. When providing care for a client with an acute burn injury. which nursing intervention is most important to prevent infection by autocontamination?

Avoiding sharing equipment such as blood pressure cuffs between clients

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

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 different parts of the client’s body can prevent autocontamination.

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 different parts of the client’s body can prevent autocontamination.

8. Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?

Allowing family members to change his dressings

Discussing future surgical reconstruction

Performing his own morning care

Wearing the pressure dressings as ordered

Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth. which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications. but will not increase self-perception.

Explanation

Indicators that the client with a burn injury has a positive perception of his appearance includes the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth. which are closely linked to body image. Allowing others to change the dressing and discussing future reconstruction would not indicate a positive perception of appearance. Wearing the dressing will assist in decreasing complications. but will not increase self-perception.

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

Administers a laxative

Documents the finding

Increases the IV flow rate

Repositions the client onto the right side

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. It is not the highest priority of care at this time.

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. It is not the highest priority of care at this time.

10. The client has burns on both legs. These areas appear white and leather-like. No blisters or bleeding are present. and there is just a "small amount of pain." How will the nurse categorize this injury?

Full-thickness

Partial-thickness superficial

Partial-thickness deep

Superficial

The fluid remobilization phase improves renal blood flow. increases diuresis. and restores blood pressure and heart rate to more normal levels. as well as laboratory values.

Explanation

The fluid remobilization phase improves renal blood flow. increases diuresis. and restores blood pressure and heart rate to more normal levels. as well as laboratory values.