BURNS ACTUAL AND FINAL EXAM
COMPLETE SOLUTION WITH QUESTIONS
AND ANSWERS GRADED A+
A client is brought to the emergency department having been involved in a fire while putting
lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be
dry and pale white with some areas that are brown and leathery. Which of the following types of
burns does the nurse determine are present?
ANSWER : Third degree (full thickness)
Rationale:
Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They are
insensate and usually present as dry, pale, white, red brown, leathery, or charred. First degree or
superficial burns involve the outer layer of the skin and are similar to sunburn, reddened without
blisters. Second degree burns or partial thickness burns involve the dermis and have a reddened,
blistered appearance. Fourth degree burns involve the dermal layers as well as the fat, fascia,
muscle, and may also include bone.
A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention
should be included in the plan of care before a hydrotherapy treatment is initiated?
ANSWER : Administer pain medication 30 minutes before therapy to help manage pain.
Rationale:
Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for
pain about 30 minutes before the treatment in anticipation of the increased pain the client will
experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy
session. However, electrolyte loss can occur from open wounds during immersion, so the
sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45
minutes before hydrotherapy unless it is an individualized need for a given client. Topical
antibiotics are applied after hydrotherapy
The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over
40% of the body. A family member asks why the client isn't reporting of more pain. Which of
the following is the best response by the nurse?
,ANSWER : "The severe burns have damaged nerves that sense pain."
Rationale:
Full-thickness burns damage nerve endings and initially may feel somewhat painless.
Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate
pain medication, and burns that are not deep enough would not be the most likely explanation of
the client's lack of reports of pain.
When teaching the diabetic client about foot care, what should the nurse instruct the client to do?
ANSWER : Avoid going barefoot.
Rationale:
The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and
decreased circulation. The client should be taught to avoid going barefoot to prevent injury.
Shoes that do not fit properly should not be worn because they will cause blisters that can
become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight
across. A heating pad should not be used because of the risk of burns due to insensitivity to
temperature.
A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30
minutes before the bath?
ANSWER : Administer an analgesic.
Rationale:
Removing dressings from severe burns exposes sensitive nerve endings to the air, which is
painful. The client should be given a prescribed analgesic about one-half hour before the
dressing change to promote comfort. The other activities are done as part of the whirlpool and
dressing change process and not one-half hour before hand
The nurse is performing triage in the emergency department. Which client should be seen first?
ANSWER : The client with burns to his chest and neck with singed nasal hair.
, Rationale:
The client with burns to the chest and neck has the potential to develop decreased lung
expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress
syndrome. Flank pain and open fractures will not take precedence over the client with airway
problems. The primipara still has time before the baby comes.
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV
fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion
pump? Record your answer as a whole number.
ANSWER : 250mL
*RATIONALE:
*2,000 mL ÷ 8 hours = 250 mL/hour
Which client with burns will most likely require an endotracheal or tracheostomy tube?
A client who has
ANSWER : thermal burns to the head, face, and airway resulting in hypoxia.
Rationale:
Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal
intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who
have experienced burns to the face and neck usually will be compromised within 1 to 2 hours.
Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the
chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation
does influence an individual's respiratory status but does not require intubation unless the
individual has an allergic reaction to the smoke.
What should be a priority for a 6-year-old child admitted with third-degree burns?
Start an IV line.
Insert an indwelling urinary (Foley) catheter.
Obtain baseline laboratory studies.
COMPLETE SOLUTION WITH QUESTIONS
AND ANSWERS GRADED A+
A client is brought to the emergency department having been involved in a fire while putting
lighter fluid on a grill. The client sustained burns to both arms. The nurse assesses the burns to be
dry and pale white with some areas that are brown and leathery. Which of the following types of
burns does the nurse determine are present?
ANSWER : Third degree (full thickness)
Rationale:
Third-degree burns involve the epidermis, dermis, and sometimes subcutaneous tissue. They are
insensate and usually present as dry, pale, white, red brown, leathery, or charred. First degree or
superficial burns involve the outer layer of the skin and are similar to sunburn, reddened without
blisters. Second degree burns or partial thickness burns involve the dermis and have a reddened,
blistered appearance. Fourth degree burns involve the dermal layers as well as the fat, fascia,
muscle, and may also include bone.
A client's burn wounds are being cleaned twice a day in a hydrotherapy tub. Which intervention
should be included in the plan of care before a hydrotherapy treatment is initiated?
ANSWER : Administer pain medication 30 minutes before therapy to help manage pain.
Rationale:
Hydrotherapy wound cleaning is very painful for the client. The client should be medicated for
pain about 30 minutes before the treatment in anticipation of the increased pain the client will
experience. Wounds are debrided but excessive fluids are not lost during the hydrotherapy
session. However, electrolyte loss can occur from open wounds during immersion, so the
sessions should be limited to 20 to 30 minutes. There is no need to limit food or fluids 45
minutes before hydrotherapy unless it is an individualized need for a given client. Topical
antibiotics are applied after hydrotherapy
The nurse is caring for a teenage client on a burn unit who has sustained third-degree burns over
40% of the body. A family member asks why the client isn't reporting of more pain. Which of
the following is the best response by the nurse?
,ANSWER : "The severe burns have damaged nerves that sense pain."
Rationale:
Full-thickness burns damage nerve endings and initially may feel somewhat painless.
Regeneration of the nerve endings in recovery may cause significant pain. Confusion, adequate
pain medication, and burns that are not deep enough would not be the most likely explanation of
the client's lack of reports of pain.
When teaching the diabetic client about foot care, what should the nurse instruct the client to do?
ANSWER : Avoid going barefoot.
Rationale:
The client with diabetes is prone to serious foot injuries secondary to peripheral neuropathy and
decreased circulation. The client should be taught to avoid going barefoot to prevent injury.
Shoes that do not fit properly should not be worn because they will cause blisters that can
become nonhealing, serious wounds for the diabetic client. Toenails should be cut straight
across. A heating pad should not be used because of the risk of burns due to insensitivity to
temperature.
A client with burns is to have a whirlpool bath and dressing change. What should the nurse do 30
minutes before the bath?
ANSWER : Administer an analgesic.
Rationale:
Removing dressings from severe burns exposes sensitive nerve endings to the air, which is
painful. The client should be given a prescribed analgesic about one-half hour before the
dressing change to promote comfort. The other activities are done as part of the whirlpool and
dressing change process and not one-half hour before hand
The nurse is performing triage in the emergency department. Which client should be seen first?
ANSWER : The client with burns to his chest and neck with singed nasal hair.
, Rationale:
The client with burns to the chest and neck has the potential to develop decreased lung
expansion. Singed nasal hair is indicative of inhalation injury and delayed respiratory distress
syndrome. Flank pain and open fractures will not take precedence over the client with airway
problems. The primipara still has time before the baby comes.
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of IV
fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion
pump? Record your answer as a whole number.
ANSWER : 250mL
*RATIONALE:
*2,000 mL ÷ 8 hours = 250 mL/hour
Which client with burns will most likely require an endotracheal or tracheostomy tube?
A client who has
ANSWER : thermal burns to the head, face, and airway resulting in hypoxia.
Rationale:
Airway management is the priority in caring for a burn client. Tracheostomy or endotracheal
intubation is anticipated when significant thermal and smoke inhalation burns occur. Clients who
have experienced burns to the face and neck usually will be compromised within 1 to 2 hours.
Electrical burns of the hands and arms, even with cardiac arrhythmias, or a chemical burn of the
chest and abdomen is not likely to result in the need for intubation. Secondhand smoke inhalation
does influence an individual's respiratory status but does not require intubation unless the
individual has an allergic reaction to the smoke.
What should be a priority for a 6-year-old child admitted with third-degree burns?
Start an IV line.
Insert an indwelling urinary (Foley) catheter.
Obtain baseline laboratory studies.
