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Burns Case
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Which action is included when a Level I disaster is declared? -
ANSWERS -All local hospitals prepare to receive casualties.
Which action should the nurse implement to help these family
members cope with this tragedy? - ANSWERS -Designate
specific family areas that are staffed with counselors. EMS personnel triage clients, with multiple casualties noted. Which action should the triage nurse implement first? -
ANSWERS -Place a disaster tag securely on each victim.
Triage determines in what order a client is seen by a healthcare provider (HCP). Which of the following clients would the nurse
identify with a red tag? (Select all that apply.) - ANSWERS -A
client whose vital signs include respirations at 22 breaths/min, pulse at 120 beats/min, and blood pressure at 85/52 mmHg. A client with a pulsating femur wound. A client with full thickness burns over 50% of the body. Which triage category should the nurse assign to client? -
ANSWERS -Priority 1, Color Red.
The client has many physical, emotional, and psychosocial needs. Which intervention is most important for the nurse to implement
upon admission? - ANSWERS -Establish and maintain an open
airway. The nurse should document which percentage of body surface? -
ANSWERS -45%.
Client grimaces in pain as the nurse assesses his red and blistered wounds that are affecting his epidermis and dermis. Based on this assessment, which finding best describes his burns? -
ANSWERS -Partial thickness or second degree burns.
Based on the nurse's understanding of the Parkland Formula, which rate correctly describes the time the fluid is given to the
client? - ANSWERS -The nurse administers the first half of the
fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours.
A child who weighs more than 30 kg (66 lbs) should produce 30 mL/kg (30 mL/2.2 lbs) to 50 mL/kg (50 mL/2.2 lbs) per hour. The client is receiving an escharotomy to treat his burn complications. Which information is accurate for the nurse provide
to his parents? - ANSWERS -"The HCP will make an incision in
his leg to relieve the pressure." An escharotomy is a surgical incision into the eschar to relieve the constricting effect of the burned tissue. It is appropriate for the nurse to give a client's mother accurate information. While caring for a client who has burns, which nursing intervention is essential in minimizing client's potential for
infection? (Select all that apply.) - ANSWERS --Inform the client's
family members that plants and flowers are not allowed in his room. Plants and flowers are not allowed because stagnant water is a potential source of bacterial growth. -Provide visitors with isolation gowns and instruction in hand hygiene. A major responsibility of the nurse is detecting infection and protecting client from infection. This must be balanced with the need for 14-year-old client to be able to visit with family and friends. Cleaning the wound and preventing infection are priorities of care. The client is scheduled for daily total immersion hydrotherapy.
Which intervention should the nurse implement during his
hydrotherapy? (Select all that apply.) - ANSWERS --Active range
of motion exercises of his extremities. Hydrotherapy provides an excellent opportunity for exercising the extremities, an important action to help prevent contractures. -Wash burn areas thoroughly and gently with mild soap and water. This is the procedure used during hydrotherapy to debride the client's burns. The HCP has prescribed mafenide acetate for the client's burned areas for application to the burn wounds twice a day. Topical agents such as mafenide acetate solution that deeply penetrate tissue are used to cover the wound. To prepare the client for this treatment, which intervention should the nurse implement? -
ANSWERS -Premedicate with an opioid analgesic 20 minutes
prior to applying this medication. This medication causes severe burning pain for up to 20 minutes after the application. Premedicating a client with an analgesic helps reduce this pain. A burn injury such as the client's produces a profound metabolic need. The client requires sufficient nutrients for wound healing and increased metabolic demands. The client can take oral nutrients and requests an evening snack. Which snack is best for
the nurse to provide? - ANSWERS -A peanut butter sandwich.
client's needs during his hospital stay? (Select all that apply.) -
ANSWERS --Allow his parents to bring in CD's and video games.
Adolescents usually enjoy listening to music and playing video games. These types of activities should be good distractions for the client. -Inform the parents that a laptop computer with internet access would be good for their son's socialization needs. The client is an adolescent with need for peer contact. The computer could keep him in touch with peers and provide a distraction for him. Psychosocial Integrity The client continues to improve and is scheduled for surgery to graft the burned areas. A nurse with whom he has established a bond is helping him with his morning care. The client says, "If I tell you something, will you promise not to tell anyone?" Question 22 of 32
How should the nurse respond to client? - ANSWERS -If I'm
concerned that it will affect your care, then I will have to tell someone." Which response by the nurse has the highest priority? -
ANSWERS -"Have you thought about how you would kill
yourself?" It is the nurse's priority to assess the seriousness of the client's statement about killing himself. The more specific the plan, the higher the chance of a suicide attempt. His remarks must be
taken seriously, and he should be referred to the proper professional for help. Reduction of Risk Potential Client continues his recovery both physically and mentally. The nurse discusses wound care and surgical debridement of the burn wounds with client and his parents. Question 24 of 32
Which intervention has the highest priority? - ANSWERS -Ensure
meticulous hand washing before and after the client's care. Proper hand washing is the most important intervention to help minimize the risk of cross-contamination and the spread of bacteria.
Which action should the nurse implement? - ANSWERS -Outline
the drainage on the dressing and write the date and time. The amount of drainage, the date and time, and the nurse's initials should be labeled on the bandage to assist the caregivers in monitoring the client for complications. Reduction of Risk Potential The client's partial-thickness and full- thickness burns require an autograft to both of his lower extremities. The procedure is explained to the client and his parents, and informed consent is obtained from his parents. The client's father asks the nurse, "Where do they get the skin to do the graft? I know the HCP told us about it, but I still don't understand."
This assessment finding is normal. A moist gauze dressing is applied to the donor site to maintain pressure and to stop any oozing. The nurse should document that the dressing is intact. Reduction of Risk Potential The client's graft sites are healing, and he is transferred to the burn rehabilitation unit. The nurse teaches client about the importance of wearing pressure garments for about a year after going home. Question 29 of 32 How should the nurse explain to the client the rationale for
wearing these pressure garments? - ANSWERS -"The pressure
stocking will help prevent scarring that could occur while the burn is healing." Pressure garments help the areas that are prone to hypertrophic scarring. The client may have to wear pressure garments for up to 1 year. This response also addresses his developmental stage because scarring represents a threat to the client's body image. The client has a positive attitude toward his rehabilitation. He adheres to the prescribed regimen and works with the physical and occupational therapists. He is looking forward to going home, although he expresses concern about how the students will act and whether he will be able to participate in band and soccer when he is able to return to school. Question 30 of 32
Which action should the nurse implement? - ANSWERS -Refer
the client to an adolescent burn support group.
Through a support group, the client can meet others with similar experiences and learn coping strategies to help him deal with his fears and concerns. Safety and Infection ControlThe multidisciplinary healthcare team is discussing discharge planning for the client. The team is apprehensive because both of the client's parents work outside the home, and he is not ready to be home alone. Question 31 of 32 Which action should be implemented to address this issue? -
ANSWERS -Determine if there is a family member who can stay
with the client during the day. This action may identify someone the client knows and trusts who can stay with him without straining the family's resources. After the client's discharge is discussed with his parents, it is determined that the client's 65-year-old grandmother is able to stay with him during the day. She lives 3 miles from his home and is very willing to stay with him as long as he needs her. The nurse meets with the client, his parents, and his grandmother for discharge teaching. Question 32 of 32 Which discharge preparation has the highest priority? -
ANSWERS -Provide specific written instructions for the client's
home care before releasing him to go home. Written instructions are the best teaching tool and resource for a client and family.
