A. How to maintain home smoke detectors B. Joining a community reintegration program C. Learning to perform dressing changes D. Options available for scar removal
A. Begin intravenous fluids. B. Check the pulses with a Doppler device. C. Obtain a complete blood count (CBC). D. Obtain an electrocardiogram (ECG).
A. Administer digoxin B. Perform chest physiotherapy C. Monitor urine output D. Place the client in an upright position
A. Have the client turn the head from side to side. B. Keep the client in a supine position without the use of pillows. C. Keep the client in a semi-Fowler’s semi-Fowler’s position with her or his arms elevated. D. Place a towel roll under the client’s neck or shoulder.
A. Documenting the findings B. Loosening any dressings on the chest C. Raising the head of the bed D. Preparing for intubation
A. Documents the finding B. Obtains a family history for diabetes C. Repeats the glucose measurement D. Stops IV fluids containing dextrose
A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial
A. Full-thickness B. Partial-thickness superficial C. Partial-thickness deep D. Superficial
A. Current range of motion in all extremities B. Heart rate and rhythm C. Respiratory rate and pulse oximetry reading D. Orientation to time, place, and person
A. Hip maintained in 30-degree flexion B. Hip at zero flexion with leg flat C. Knee flexed at 30-degree angle D. Leg abducted with foam wedge
A. Assesses level of consciousness and pupillary reactions B. Ascertains the time food or liquid was last consumed C. Auscultates breath sounds over the trachea and mainstem bronchi D. Measures abdominal girth and auscultates bowel sounds
A. Acute Pain B. Deficient Diversional Activity C. Impaired Adjustment D. Imbalanced Nutrition: Less than Body Requirements
A. “Tagamet will stimulate intestinal movement.” B. “Tagamet can help prevent hypovolemic shock.” C. “This will help prevent stomach ulcers.” D. “This drug will help prevent kidney damage.”
A. “With reconstructive surgery, you can look the same.” B. “We can remove the scars with the use of a pressure dressing.” C. “You will not look exactly the same.” D. “You shouldn’t start worrying about your appearance right now.”
A. Continuing to monitor the client B. Increasing the temperature in the room C. Increasing the rate of the intravenous fluids D. Preparing to do a workup for sepsis
A. “As soon as he finishes his antibiotic prescription.” B. “As soon as his albumin level returns to normal.” C. “When fluid remobilization has started.” D. “When the burn wounds are closed.”
A. Have chimneys swept every 2 years. B. Keep a smoke detector in each bedroom. C. Use space heaters instead of gas heaters. D. Use carbon monoxide detectors only in the garage.
A. Applies silver sulfadiazine (Silvadene) ointment B. Covers the area with an elastic wrap C. Places a synthetic dressing over the area D. Removes loose nonviable tissue
A. Chimney sweeping every year B. Cooking with a microwave oven C. Use of sunscreen agents D. Use of space heaters
A. Creatinine B. Red blood cells C. Sodium D. Magnesium level
Answers and Rationale Critical for the goal of progression toward independence for the client is teaching clients and family members to perform care tasks such as dressing changes. All the other distractors are important in the rehabilitation stage. However, dressing changes have priority. Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injuries. Fluids can treat this problem. An ECG and CBC will be taken to ascertain if a cardiac or bleeding problem is causing these vital signs. However these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery but this is not an immediate nursing action. Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in the upright position can relieve the lung congestion immediately before other measures can be carried out. Digoxin may be given later to increase cardiac contractility to prevent backup of fluid into the lu ngs. Chest physiotherapy will not get rid of fluid. Monitoring urine output is important. However it is not an immediate intervention. 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. The other distractors listed do not call for moving of the head from side to side. This movement is what would prevent contractures from occurring. 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. The swelling usually precludes intubation. Neural and hormonal compensation to the stress of the burn injury in the emergent phase increase 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. A family history of diabetes could make her more of a risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid. The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters and pain present. Blisters are not seen with full-thickness and superficial burns, and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns are red to white in color. The characteristics of the wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; pain minimal; outer layer firm and inelastiC. Partial-thickness superficial burns appear pink to red in color, with pain. Partial-thickness burn color is deep red to white in color with pain, and superficial burn color is pink to red, with pain. The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. 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. Range of motion and neurologic assessments are important. However the priority is to make sure that the heart rate and rhythm are adequate to support perfusion to the brain and other vital organs. Maximum function for ambulation occurs when the hip and leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion. Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his airway because of this injury. The absence of breath sounds over the trachea and mainstem bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important to assess oxygenation to the brain. Ascertaining time of last food intake is important in case intubation is necessary (the nurse would be more alert for the signs of
aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation. Recovery from a burn injury requires a lot of work on the part of the client and significant others. The client is seldom restored to his or her preburn level of functioning. Adjustments to changes in appearance, family structure, employment opportunities, role, and functional limitations are only a few of the numerous lifechanging 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. Ulcerative gastrointestinal disease may develop within 24 hours after a severe burn as a result of increased hydrochloric acid production and decreased mucosal barrier. This process occurs because of the sympathetic nervous system stress response. Cimetidine inhibits the production and release of hydrochloric acid. Cimetidine does not affect intestinal movement, prevent hypovolemic shock, or prevent kidney damage. Many clients have unrealistic expectations of reconstructive surgery and envision an appearance identical or equal in quality to the preburn state. Pressure dressings prevent further scarring. They cannot remove scars. The client and family should be taught the expected cosmetic outcomes. These findings are associated with systemic gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out if the client has sepsis and treating it before it becomes a shock situation. Increasing the rate of intravenous fluids may be done to replace fluid losses with diarrhea, but is not the priority action. 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 high risk for infection as long as any area of skin is open. Everyone should use smoke detectors and carbon monoxide detectors in their home environment (just not in a garage). Recommendations are that each bedroom have a separate smoke detector. Space heaters can be a cause of fire if clothing, bedding, and other flammable objects are nearby. All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process is removing exudates and necrotic tissue. Minor burns are common occurrences. The use of space heaters can cause a fire if clothing, bedding and other flammable objects are near them. Chimneys should be swept each year to prevent creosote build-up and resultant fire. Burn injuries do not commonly occur from microwave cooking, but rather w hen taking food from this oven. Lastly, sunscreen agents are recommended to prevent sunburn. 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. Topical gentamicin will not affect the red blood cell count or sodium or magnesium level.
