Nokea
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
- A. Tissue hypoxia
- B. Infection
- C. Renal failure
- D. Hypovolonia
Correct Answer: D
Rationale: After a burn, fluid from the body moves toward the barmed area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the issues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that was destroyed during the burn can result in acute renal failure. Destruction of the skin barrier result in colonization of bacteria and can lead to life-threatening infection in days following the burn.
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Which is a disadvantage of surgical debridement?
- A. Scarring
- B. Bleeding
- C. Loss of function
- D. Contractures
Correct Answer: B
Rationale: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.
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.
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: D
Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. None of the other answer choices correctly applies the Rule of nines.
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 young child is being evaluated for an area of burn involvement. The nurse knows the most accurate method of assessing the total body surface area is through the use of which assessment tool?
- A. Rule of nines
- B. Lund and Browder method
- C. Hand method
- D. Parkland formula method
Correct Answer: B
Rationale: The Lund and Browder method divides the body into smaller segments. Different percentages are assigned to body parts, depending on patient's age. For example, the adult head is equivalent to 9%, whereas the infant head is 19%. This method is more accurate when dealing with children. The rule of nines and hand method are quick assessment techniques for estimating burns. The Parkland formula incorporates fluid resuscitation requirements for burns.