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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.
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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.
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
- A. The wound will take up to 3 weeks to heal.
- B. Pain management will be a challenge.
- C. Skin grafting will be necessary.
- D. Ligaments, tendons, muscles, and bone are not involved.
Correct Answer: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
Skin grafts are necessary for what type of burn?
- A. Superficial
- B. Superficial partial thickness
- C. Full-thickness
- D. First degree
Correct Answer: C
Rationale: Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.
- A. Wear the garment at least 12 hours each day.
- B. Contact the primary provider if the garment does not seem to fit properly.
- C. Machine wash the pressure garment daily with a mild detergent.
- D. Roll the garment and wring tightly to ensure garment is as dry as possible after washing.
- E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
Correct Answer: B,E
Rationale: When using a pressure garment, the nurse should instruct the client to wear the garment for at least 23 hours a day, not 12 hours a day. The client should contact the primary provider if the garment does not seem to fit. The nurse should instruct the client to hand wash, not machine wash, the pressure garment daily with a mild detergent. The garment should not be wring dry. Instead, the client should squeeze and roll the garment in a towel to remove as much moisture as possible. The client should also massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
- A. Risk for Impaired Gas Exchange
- B. Acute Pain
- C. Infection Risk
- D. Altered Tissue Perfusion
Correct Answer: A
Rationale: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.