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A client is brought to the emergency department with burns in irregular shapes scattered over multiple areas of the body. Which is the best method for the nurse to obtain a quick assessment of the total body surface area of the burn?
- A. Rule of nines
- B. Use client's palm size
- C. Parkland formula
- D. Lund and Broweder burns assessment
Correct Answer: B
Rationale: A quick assessment technique to use to evaluate an area of burn that is not restricted to one portion of the body is by using the client's palm size to approximate the total body surface. The palm is approximately 1% of a person's TBSA. The Parkland formula determines fluid resuscitation needs. Lund and Broweder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of times quantitates burns that involve entire sections of the body, not scattered burns.
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Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
- A. Myoglobin in the urine
- B. Increase in antidiuretic hormone (ADH)
- C. Elevation of blood glucose levels
- D. Hypermatremia
Correct Answer: A
Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
A nurse is caring for a client with facial burns who is prescribed the open method treatment. What nursing intervention should the nurse perform?
- A. Administer a cold sponge bath to the client.
- B. Keep the client's room cool and airy.
- C. Place a bed cradle or sheets over the client.
- D. Place the client on a moist linen sheet.
Correct Answer: C
Rationale: The skin of the client with burn is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets should be placed over the client. The room should be kept warm and humidified, not cool and airy. The client should be placed in isolation in a bed with sterile, dry linen. Whirlpool baths are prescribed to loosen the crust, or eschar, which forms over the wound. Sponge baths are not advisable because particles from the sponge may cause accumulation of debris within the burn wound. Moist linen sheets are not placed on clients anymore due to their cooling effect, and they can lead the client to work hard to maintain proper body temperature.
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client?
- A. Prevent infection
- B. Fluid resuscitation
- C. Endotracheal tube placement
- D. Strict intake and output
Correct Answer: B
Rationale: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystaloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
A nurse is monitoring the effectiveness of fluid resuscitation in a client who is being treated for burns. What assessment would indicate the success of the fluid resuscitation?
- A. The client's heart rate is rapid and regular.
- B. The client's urinary output is 0.5 to 1 ml/kg/hour.
- C. The client's breathing is unlabored, and skin is clammy.
- D. The client is alert and conscious.
Correct Answer: B
Rationale: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 ml/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts?
- A. Less scarring
- B. Less discomfort
- C. Speeds healing
- D. Rejection is unlikely.
Correct Answer: D
Rationale: In an autograft slit graft, the skin is harvested from the client's buttocks or thighs. Rejection is less likely with this type of graft because the donor and recipient are the same. There will be scarring at both the donor and recipient sites, and added discomfort is associated from the donor site. Because the slit graft is expanded through a meshing device, the scarring will appear as a mesh. Healing is delayed due to need for two wounds.