Burns Review Questions and answers

The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order of priority? Correct 1. Checking for a patent airway Correct 2. Maintaining effective circulation Correct 3. Performing adequate fluid replacement Correct 4. Caring for the burn wound A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation? Correct 1. Using a jaw­thrust maneuver to establish an airway Correct 2. Providing bag­valve­mask (BVM) ventilation Correct 3. Palpating for the presence of a radial pulse Correct 4. Monitoring systolic blood pressure Correct 5. Assessing the score of eye opening Correct 6. Removing the clothing with scissors the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin. The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment? 1 Determining the level of mobility Correct2 Removing the clothes of the client 3 Placing the client in recumbent position 4 Cleaning the wounds with antiseptic solution The nurse should remove all clothing of the client with scissors to allow for thorough assessment; this A registered nurse teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. Which statement made by the new orienting nurse indicates the new nurse needs more orientation? 1 "I should administer intravenous analgesia." Correct2 "I should check pulses distal to burns." 3 "I should prepare for an endotracheal intubation." 4 "I should anticipate the need for fiberoptic bronchoscopy." Inhalation injury burns occur in the nose, mouth, throat, and airway. The peripheral and central pulses are assessed, but they are not considered distal to the burn. The nurse should administer intravenous analgesia. The nurse should anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy. The nurse teaches a client about strategies to reduce burn injuries. Which statement made by the client indicates the need for further teaching? 1 "I should never smoke in bed." 2 "I should never use gasoline to start a fire." 3 "I should never leave hot oil unattended while cooking." Correct4 "I should never attend to burning candles near open curtains." The client should never leave candles unattended near open curtains. The client should never smoke in bed, use gasoline to start a fire, or leave hot oil unattended while cooking. A client is admitted to the hospital due to electrical burns. Which assessment findings does the nurse anticipate? Select all that apply. 1 Coughing Correct2 Burn odor 3 Smoky breath Correct4 Leathery skin Correct5 Cardiac arrest A client with electrical burns may have assessment findings such as burn odor, leathery skin, and cardiac arrest due to hypovolemia and electrical disturbances. Coughing and smoky breath are assessment findings associated with inhalational injuries. A client who sustained burn injuries due to a fire and explosion has a carbon monoxide level of 14%. Which pathophysiologic risk is increased in the client? 1 Stupor 2 Vertigo 3 Convulsions Correct4 Slight breathlessness Slight breathlessness may occur when the carbon monoxide level is 14%. Stupor and vertigo may result when the carbon monoxide level is in between 21% and 40%. When the level of carbon monoxide reaches between 41% and 60%, coma or convulsions may occur. The nurse is caring for a client with a burn injury and suspects atelectasis and hypoxia. Which age-related changes should the nurse associate these findings? 1 Reduced mobility 2 Reduced healing time Correct3 Reduced thoracic compliance 4 Reduced inflammatory and immune responses The reduction in thoracic and pulmonary compliance may increase the risk of atelectasis and hypoxia. Reduced mobility increases the risk for burn injuries. Reduced healing would have longer time with open areas, which results in greater risks for infection, metabolic derangements, and loss of function from contracture formation and scar tissue. Reduced inflammatory and immune responses would increase the risk for infection and sepsis. A client with burns is hospitalized in the emergency department and advised to get an electrocardiogram (ECG) done. Which type of burn injury has the client most likely sustained? 1 Flame burn 2 Chemical burn Correct3 Electrical burn 4 Radiation burn In an electrical burn injury, changes in the ECG may indicate damage to the heart. In flame burn injuries, the smoldering clothing and all metal objects are removed. If a client suffers from chemical burns, the dried chemicals present on skin should not be made wet but should be brushed off. If the client has radiation burn injuries, then the source should be removed using tongs or lead protective gloves. A client with burns caused by flames is hospitalized. Which specific emergency burn management would be appropriate for this client? Correct1 Removing all metal objects 2 Helping the client bathe or shower 3 Initiating cardiopulmonary resuscitation 4 Administering tetanus toxoid for prophylaxis When a client with flame burn injuries is hospitalized, the primary healthcare provider should first remove all smoldering clothing and metal objects. In case of radiation burns, the client is helped to bathe or shower. Cardiopulmonary resuscitation would be appropriate in the emergency management of an electrical burn injury. The administration of tetanus toxoid for prophylaxis would be considered as the general management for all types of burns. While caring for a client with a burn injury and in the resuscitation phase, the nurse notices that the client is hoarse and produces audible breath sound on exhalation. Which immediate action would be appropriate for the safe care of the client? Select all that apply. Correct1 Providing oxygen immediately Correct2 Notifying the rapid response team 3 Considering it a normal observation 4 Initiating an intravenous (IV) line and beginning fluid replacement 5 Obtaining an electrocardiogram (ECG) of the client Hoarseness of voice, difficulty in swallowing, or an audible breath sound on exhalation after a burn injury indicates an impaired airway. Therefore the client should be given oxygen immediately. The rapid response team should also be notified for further management. This occurrence should not be considered a normal observation. An IV line should be initiated for fluid replacement only once the client’s airway is patent. An ECG is obtained when the client suffers from electrical burns. The nurse is caring for a client with burns receiving opioid analgesics and who is sedated. Which medications should the nurse anticipate to be prescribed by the primary healthcare provider to overcome this side effect of the opioid analgesics? Select all that apply. 1 Morphine Correct2 Pregabalin 3 Lorazepam 4 Midazolam Correct5 Gabapentin Pregabalin and gabapentin are adjuvant analgesics used to overcome the side effects caused by opioid analgesics. Morphine is an opioid analgesic used in the treatment of pain that can cause sedation. Lorazepam and midazolam are anxiolytic agents used to inhibit anxiety. The registered nurse is teaching the student nurse about precautions to take when treating a client with open burn wounds. Which statement made by the student nurse indicates the need for further teaching? Correct1 I should use non­sterile gloves when applying ointments." 2 "I should use non­sterile, disposable gloves when removing old dressings." 3 "I should wear personal protective equipment before caring for the client." 4 "I should remove personal protective equipment before leaving one client to treat another." Sterile gloves are used when applying ointment to the open burn wounds. When removing contaminated dressings and washing the dirty wound, non­sterile, disposable gloves are used. When treating the client, personal protective equipment like disposable gowns and gloves are used. To prevent crosscontamination, the nurse should remove the personal protective equipment before leaving one client to treat another. Which wound care is given to a client with severe burn injuries during the acute phase? 1 Assess extent and depth of burns 2 Provide daily shower and wound care 3 Remove dead and contaminated tissue Correct4 Assess the wound daily and adjust the dressing In the acute phase, wound care is given by assessing the wound daily and adjusting the dressing if necessary according to the protocols. Assessing the extent and depth of burns is performed in the emergent phase. Providing a daily shower and removing the dead and contaminated tissue (debride) is performed in the emergent phase. The registered nurse is teaching a student nurse about the ongoing monitoring of a client with electrical burns. Which statement made by the student nurse indicates the need for further teaching? 1 "I should monitor the airway." Correct2 "I should monitor the eye pH." 3 "I should monitor vital signs." 4 "I should monitor urine output." The pH of the eye is monitored when chemical burns occur to the eye. The nurse should monitor the airway for breathing, vital signs, heart rhythm, neurovascular status of injured limbs, level of consciousness, and urine output. A client has burn injuries sustained from an electrical current. What are the interventions to follow until the client is transferred to the primary healthcare center? Select all that apply. 1 Cover the burns with ice. Correct2 Leave the adherent clothing in place. Correct3 Wrap the client in a dry clean sheet. Correct4 Remove as much burned clothing as possible. 5 Immerse the burned body part in cool water. When a client is injured due to an electrical current, the adherent clothing should be left in place until the client is transferred to a primary healthcare center. Wrapping the client in a clean dry sheet may prevent further contamination of the wound and also provide warmth. Removing as much burned clothing prevents further tissue damage. The burns should not be covered with ice, since this may cause hypothermia and vasoconstriction of blood vessels. Do not immerse the burned body part in cool water because it may cause extensive heat loss. A client was admitted with a burn injury caused by a quick heat flash. The nurse examined the skin and noticed erythema and mild swelling. What type of burn does the nurse suspect? Correct1 First­degree burn 2 Third­degree burn 3 Fourth­degree burn 4 Second­degree burn A burn injury caused by a quick heat flash is a first­degree burn or superficial burn and is manifested as erythema and mild swelling on the skin. Third­degree and fourth­degree burns are caused by flame, scald, chemicals, tar, and electric shock and typically involve damage to muscles, tendons, and bones; the client presents with dry, waxy white, leathery skin. Second­degree burns include contact burns and those associated with third­and fourth­degree burns, but they are much less severe and are characterized by fluid­filled vesicles that are red, shiny, and wet. A man who has 40% of the body surface area burned is admitted to the hospital. Fluid replacement of 7200 mL during the first 24 hours has been prescribed. Fifty percent of fluid replacement should be administered in the first 8 hours;