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Burns #1

Nursing

QuestionAnswer
Tissue destruction caused by a burn injury causes local & systemic problems. Identify 8 of these potential problems. 1.Fluid & protein losses 2. Sepsis 3.Disturbances of met system 4.Disturbances of endocrine system 5.Disturbances of respiratory system 6.Disturbances of cardiac system 7.Disturbances of hematologi system 8.Disturbances of immune system
Dermal appendages Sweat and oil glands, and their hair follicles
Anesthetic Does not transmit sensation
Avascular Without a blood supply
Eschar Burn crust
Desquamation Peeling of dead skin
Fasciotomy Incision through eschar and fascia
Viable Living
Hyperkalemia Elevated potassium levels
Hyponatremia Decreased sodium levels
Hemoconcentration Elevated blood osmolarity; hemoglobin & hematocrit
When a burn injury occurs, the skin can regenerate as long as which of the following occurs? A.Epidermis layer is present B.Nerve tissue is intact C.Parts of dermis layer remain D.There is no infection present C.Parts of the dermis layer remain
(T/F) The depth of dermal appendages is equal across body areas. False
(T/F) Full-thickness burn is identified by the total destruction of the dermis. True
(T/F) Ful-thickness burn results in loss of excretory ability. True
(T/F) All burn injuries are painful. False
(T/F) The skin can tolerate temperatures of 158*F. False
(T/F) The magnitude of the injury is based on the depth and extent of the total body surface burn. True
(T/F) Blood transfusions are critical in the first 24 hours for all burns. False
Partial thickness wounds can convert to full thickness when which of the following occur?A.Scar formation is large B.Tissue damage ^ withischemia C.Blisters are present D.Skin integrity is impaired B. Tissue damage increases with ischemia
Which of the following describes full-thickness wound healing? Check all that applyA.Healing occurs by wound contraction B.Eschar must be removed C.Lrg blisters are protective & left undisturbed D.Skin grafting may be necessary A.Healing occurs by wound contractionB.Eschar must be removedD.Skin grafting may be necessary
Which of the following describes #rd spacing or capillary leak syndrome in sever burn client? A.Usually happens in 1st 36-48 hrs B.Is a leak of plasma fluids into interstitial space C.Is present even in unburned tissue D.Can usually be prevented B.Is a leak of plasma fluids into the interstitial space
As a result of 3rd spacing, during the acute phase,which of the following electrolyte imbalances occur? Chaeck all that applyA.Hyperkalemia B.Hypokalemia C.Hypernatremia D.Hyponatremia E.Hypocalcemia F.Hypercalcemia A.HyperkalemiaD.Hyponatremia
Because of fluid shifts in burns, which of the following regarding cardiac output is correct?A.It is not affected B.It may be depressed up to 36 hrs after the burn C.It is depressed with fluid restriction D.It responds to diuretics B.It may be depressed up to 36 hrs after the burn
What is the major source of respiratory problems related to burn injury? Exposure to superheated air, steam, toxic fumes, or smoke rather than a direct burn injury
Which of the following is a serious GI problem that can occur with a major burn? A.Increased motility B.Increased flow of blood to area C.Decreased secretion of catecholamines D.Paralytic ileus D.Paralytic ileus
The hypermetabolic state with a significant burn causes which of the following? All that apply A.Fat breakdown & rapid use of glucose & calories B.A decrease in secretion of catecholamines C.An increase in caloric needs D.An increase in core temperature A.Fat breakdown & rapid use of glucose & caloriesC.An increase in caloric needsD.An increase in core temperature
Whic of the following statements about remobilization are true? All that applyA.Anemia may be present B.Metabolic alkalosis may occur C.Hyponatremia may develop D.Hyperkalemia may develop A.Anemia may be presentC.Hyponatremia may develop
Tissue injury is a threat to homeostasis. What are the 2 compensatory responses? 1.Sympathetic nervous system stress response2.The inflammatory response
Identify 6 sources of burn injuries 1.Dry heat 2.Moist heat 3.Contact burns4.Chemical injury 5.Electrical injury 6.Ionizing radiation injury
Local tissue resistance to electricity varies in different parts of the body. Which of the following has the MOST resistance?A.Skin epidermis B.Tendons & muscle C.Fatty tissue D.Nerve tissue & bllod tissue A.Skin epidermis
Identify info that should be included in a history. Time of injury, source of injurious agent,alcohol or drugs factor, physical surroundingswhere burn was sustained, events from burn to admission
A client who has been rescued from a burning house has been treated with oxygen. His breath sounds previously, included wheezing, but after 30 min, the wheezing has stopped. What action, if any, should the nurse take at this time? This finding indicates impending airway obstruction & demands immediate intubation.
Which of the following lab results would be expected during the emergent period? All that apply A.K+ of 3.2mEq/L B.Glucose of 180mg/dL C.Hct of 49%/dL D.pH of 7.20 B.Glucose of 180 mg/dLC.Hct of 49%/dLD.pH of 7.20
Which are true about carbon monoxide poisoning? All that apply A.It causes "cherry-red" color in burn clients B.The PaO2 dissolved in arterial blood is reduced C.Carbon monoxide binds to Hgb 250x more tightly then O2 D.It has a high mortality rate A. It causes "cherry-red" color in burn clientsC.Carbon monoxide binds to Hgb 250x more tightly then O2D.It has a high mortality rate
What should a nurse assess relevant to the cardiovascular system for the client with severe burns? All that apply A.Presence & strength of peripheral & central pulses B.Capillary refill C.Presence of edema D.Noninvasive BP A.Presence & strength of peripheral & central pulsesB.Capillary refillC.Presence of edema
Which is the best way to assess renal function in client with severe burns? A.Measuring urine output & comparing this value with fluid intake B.Weighing the client C.Noting amount of edema D.Measuring abdominal girth A.Measuring urine output & comparing this value with flui intake
Why is it important to be accurate when evaluating the size of the burn injury? It is important for diagnosis & prognosis but also for calculating specific interventions such as drug doses, fluid replacement volumes, & caloric requirements
For an African-American client with a burn injury, an additional blood test may be appropriate. Which test is it & why? Sickle cell preparation. Trauma often triggers a sickle cell crisis in clients who have the disease & in those who carry the trait. AA are at significant risk for sickle-cell disease
Hypovolemic shock occurs in burned clients as a result of which? A.Erratic lymphatic drainage B.Altered osmotic pressure in vessels C.Albumin trapped in interstitial spaces D.A marked increase in capillary permeability D. A marked increase in capillary permeability
A 70-kg woman with 50% TBSA burn arrived at 11am & was burned at 9am, according to her family. Q.Using the Parkland(Baxter)formula, calculate the fluids needed for the 1st 8 hrs after injury 7000 mL in first 8 hours
A 70-kg woman with 50% TBSA burn arrived at 11am & was burned at 9am, according to her family. Q.What time does the first 8-hr period end? Ends at 5 pm
A 70-kg woman with 50% TBSA burn arrived at 11am & was burned at 9am, according to her family. Q.How much fluid is required for the 24 hours? 14,000 mL
A 70-kg woman with 50% TBSA burn arrived at 11am & was burned at 9am, according to her family. Q.Hourly urine output is adjusted to_________mL/kg. 0.5 mL/kg (30 mL/hr
Which statements are true about escharotomies & fascotomies? A.They are frequently done under general anesthesia B.No anesthesia is req C.Sedation & analgesia are commonly given to reduce anxiety D.They are often done at the bedside B.No anesthesia is requiredC.Sedation & analgesia are commonly given to reduce anxiety D.They are often done at the bedside
Airway maintainance for client w/ burn injury & resp involvement includes?A.Monitor S&S of upper airway edema during fluid resusc B.Insert nasoph or oroph airway when airway completely obstructed C.Securing loose dressing w/ rib binder instead of tape A. Monitoring for signs & symptoms of upper airway edema during fluid resuscitation
When does fluid remobilization occur?A.W/in 1st 4 hrs after burns were sustained B.After scar tissue is formed & fluids are no longer being lost C.After 36 hrs, when fluid is reabsorbed from interstitial tissue D.Immediately after burns occur C. After 36 hours, when the fluid is reabsorbed from the interstitial tissue
Which is true about pain associated w/ burn injuries? A.Pain is both chronic & acute B.Preferred route of admin of narcs in emergent state is intravenous C.Massaging nonburn areas may reduce pain D.Cool room temp to reduce discomfort from injuries A.The pain is both chronic & acuteB.The preferred route of admin of narcs in emergent state is intravenousC.Massaging nonburn areas may reduce pain
Which about the acute phase of burn injury id true? A t apply A.Begins 24 hr after injury,lasts until wound closure complete B.During this time, client is high risk for infection C.Caloric req are decreased in this phase D.Pneumonia is pot complication B.During this time, the client is at high risk for infectionD.Pneumonia is a potential complication during this phase
Which applies to the debridement procedure? All that apply. A.Remove eschar, cellular debris from wound B.Nonviable tissue is removed during hydrotherapy C.Sterile saline used D.Sml blisters are usually opened E.Includes mechanical & enzymatic actions A.Remove eschar & other cellular debris from the woundB.Nonviable tissue is removed during hydrotherapyE.Includes both mechanical & enzymatic actions
What is a biological dressing called that uses skin from a cadavar provided from a skin bank?A.Heterograft B.Xenograft C.Allograft D.Autograft C.Allograft
What type of wound is created in the typical donor site? A.Stage 1 B.Partial thicknessC.Full thickness D.Stage 4 B.Partial thickness
Drug therapy to reduce risk of wound infection includes?(ATA) A.Tetanus toxiod IM prophylactically once early in hospital B.Silver nitrate solution covered by dry dress applied q4hr C.Sulfadine on full-thick injuries q4hr D.Brd-spec ABT given IVq4hr D. A. Tetanus toxoid given IM prophylactically once early in hospitalizationC. Sulfadine (silver sulfadiazine)on full-thickness injuries q4hr
Early detection of wound infection is important. The wound should be examined for which six signs of infection? 1.Pervasive odor 2.Color changes 3.Change texture 4.Purulent drainage 5.Sloughing grafts 6.Redness at wound edges extending into nonburned skin
Nutritional req for a client w/ arelatively large burn area can exceed which? a.1500kcal/day B.2000 kcal/day C.3000kcal/day D.5000 kcal/day D.5000 kcal/day
After a dressing is applied to a client's ankle, the ankle is placed in which positions? A.Dorsiflexion B.Adduction C.External rotation D.Hyperextension A. Dosiflexion
Client w/ severe burns progresses through typical stages & exhibits which feelings?(ATA) A.Denial B.Regression C.Anger D.Suicidal A.Denial B.Regression C.Anger
Which intervention best promotes a positive image in a burn client? A.Physician discussess future scar revision w/ client B.Dietician helps client select choices from menus C.Spouse plays cards w/ client D.Nurse applies pressure garment upon discharge A. The physician discussess future scar revision with the client
A 28-yr male sustained 2nd & 3rd* burns on legs (30%)when his clothing caught fire while he was burning leaves. He was hosed down and has arrived in severe discomfort. Identify priority diagnosis at this time Acute pain r/t damaged or exposed nerve endings
A client's burn wound has developed an infection w/ MRSA. Is this an example of autocontamination or cross-contamination? Cross-contamination. b/c organisms from elsewhere are transferred to client. Through autocontamination, client's normal flora overgrows & penetrates the wound
Which client has the highest risk for a fatal burn injury? A.4-yr-old child B.32-yr-old man C.45-yr-old woman D.77-yr-old man D. 77 year-old man
A client has noticed that skin is peeling off 3 days after a severe sunburn. What is this called? Desquamation
Also known as "burn crust" Eschar
The nurse monitors for this severe complication of a full-thickness burn by watching for tachycardia, decreased BP & peripheral pulses,& other signs of decreased cardiac output Shock
After spending the day at the beach, a teenage girl has a severe sunburn. This is an example of a _______-thickness burn. Superficial
_________-thickness burn involves the entire epidermis and varying parts of the dermis. Partial
To assess whether a superficial partial-thickness wound is present, the nurse notes that the wound is red, moist, and _______ when pressure is applied. Blanch
A client is admitted to a burn trauma unit after suffering a severe electrical shock. He is in the _______ phase of burn injury. Emergent
A client is admitted to a burn trauma unit after suffering a severe electrical shock. He has has severe edema. This is due to a fluid shift, known as ______ _______. Third spacing
Client who was admitted w/ severe burn after spilling hot liquid on his legs will be receiving a heterograft. The most common heterograft, which is compatible w/ human skin, is made from ___________. Pigskin
A client is admitted to a burn trauma unit after suffering a severe electrical shock. He has has severe edema. After 48 hrs,clientbegins to produce lrg amounts of urine. This is known as fluid ___________. Remobilization
A client is admitted after a house fire w/ severe burns across her body. The burns have destroyed the entire epidermis & dermis layers. This is known as a ____-thickness wound. Full
A camper spills bacon grease on his foot while cooking breakfast. This type of burn is a ___ burn Contact
An elderly man tips over a tea kettle w/ boiling water & burns the skin of his abdomen & thighs. This type of heat injury is a ______ burn, or a scald. Moist
A client suffers burns on her arms after the sleeves of her robe catch fire while she is cooking breakfast. This type of burn injury is known as a ______ heat injury. Dry
A client w/ partial thick wounds of face & chest caused by a campfire is admitted. All have been ordered. Which one should nurse do first? A.O2/non-breath mask at 100% FIO2 B.Infuse LR at 150 mL/hr C.Morphine 4-10 mg IV(pain) D. Insert 14 F retention cath A. Give O2/ non-breather mask at 100% FIO2
The nurse received change of shift report. First? A.20yr from wk ago w/deep part thick burns(35%)complaining pain 7 B.26yr w/smoke inhal & face burn,says"I can't catch my breath" C.50yr electrician external burns month ago,asking call dr now for discharge B. A 26-yr-old firefighter with smoke inhalation and facial burns who just arrived on the unit and whispers "I can't catch my breath"
While working in ER, RN admits client w/ extensive burns by a hone fire. Which RN does first? A.TBSA burned B.Breath sounds C.Pain level D.BP B. Breath sounds
Using Parkland (4mL/kg),what vol of fluid should be admin in 1st 8hr to an 80kg client w/30% total body surface burn? 4800 mL
Nurse notes which as signs of an infected burn wound?(ATA) A.Swell of skin around wound B.Hypoglycemia C.^BP D.Tachycardia E.^ wound drainage F.Dry,crusted granulation tissue A>Swelling of skin around wound D.TachycardiaE.^ wound drainage F.Dry,crusted granulation tissue
During emergent phase of burn injury,what route is used to admin pain meds? A.IV B.Topical C.SQ D.IM A. IV
In assessing client in rehab phase of therapy, nurse anticipates which ND? A.Acute pain B.potential for infection C.Impaired body image D.Fluid vol excess C. Impaired body image
In caring for client burns to face,which by client req future exploration by RN? A."I don't know what I will do when people stare" B."I am getting used to looking at myself C."My spouse doesn't stareat scars like in begin D."I knowI won't look like I used A. "I don't know what I will do when people stare at me"
In eval of effectiveness of fluid resusc in emergent pahse, RN correlateswhich clinical improvement? A>urine output 40mL/hr B.BUN 36 C.Creatinine 2.8 D.Urine spec grav 1.042 A. Urine output 40 mL/hr
In positioning client burns upper extremities, RN positions elbow? A.In position of comfort B.Slightly hyperextended C.Slightly flexed D.In neutral position D. In neutral position
Preparing present of safety, RN identifies which group at ^risk for fir burns? A.2-4 yr-old B.19-35 yr-old C.35-44 yr-old D.>75 yrs D. older than 75 years of age
In acute phase of injury, priority nutritional need is? A.Electrolyte replacement B.Protein intake C.CHO consumption D.Vitamin supplementation B. Protein intake
Lund-Browder methos, adult burns to head,neck,anterior trunk,RN calculates TBSA burned to be: A.18% B.22% C.26.5% D.31.5% B. 22%
Nurse correlates which clinical manifestation as indicative of wound healing in acute phase? A.^ wound drainage B.Dry,light pink wound bed C.Scar tissue formation D.Sloughing of eschar C. Scar tissue formation
Nurse correlates which neural compensation during emergent phase? A.^ urine output B.^ bowel motility C.Slow,deep respirations D.^ blood glucose D. Elevated blood glucose
The nurse prioritizes which in emergent phase? A.Assessing body temp B.Monitoring urine output C.Emotional support D.Fluid resuscitation D. Fluid resuscitation
Nurse recognizes that topical antimicrobials reduce risk of autocontamination by: A.Keeping wound sterile B.Maintaining moist wound bed C.Reducing bacterial growth D.Preventing systemic infection C. Reducing bacterial growth
Nurse recognizes which description as MOST appropriate for deep part thick burns? A.Painless,reddened blisters B.Pink blistersw/minimal local edema C.Painful red,white blisters D.painless brownish-yellow eschar C. painful red and white blisters
Which assessment would RN do 1st during acute phase? A.Bowel sounds B.Urine output C.Signs of infection D.Muscle strength C.Signs of infection
Whichmanifestation in cient w/suspected inhalation burn would require immediate intervention by RN? A.Audible wheezing B.Blistering in area of burn C.^ respiratory rate D.Thick, tan-colored sputum A. Audible wheezing
Which would indicate the need for immediate intubation w/burn injury? A.PaCO2 <35 B.^ resp rate C.PaO2<60 D.Thick,tenacious secretions C. PaO2 < 60
Which statement by client being discharged after tx for part thick 25% TBSA burn indicates need fr further teaching? A."I amstill at risk for infect" B."I need to cahnge drsg w/clean gloves" C."I need to eat adeq protein D."Scars may take months to heal" B. "I need to change the dressings with clean gloves"
The nurse is caring for a client with an electrical burn.Which structures have the greatest risk for soft tissue injury? A.Fat. tendons, & bones B.Skin & hair C.Nerves, muscle, & blood vessels D.Skin,fate & muscle A.Fat,tendon & bone have most resistance.The higher the resistance, greater heat generated by current,thereby ^ risk for soft tissue injury
Which laboratory result would be expected during the emergent phase of a burn injury? A.Glucose 100mg/dl B.Potassium 3.5 mEq/l C.Sodium 142 mEq/l D.Albumin 4.2 g/dl A.Glucose levels rise as a result of stress response during the emergent phase.
An Afr-Amer client is admitted with full-thickness burns over 40%of his body. In addition to CBC & complete metabolic panel,physician likely to request which additional bloodwork? A.Erythrocyte sed rate B.Indirect Coombs C.C-reactive protein D.Sickledex D. Sickle cell anemia and sickle cell trait are more prevelant in Afr-Amer clients.
A 76-kg client admitted at 0600 w/a TBSA burn 40%. Using Parkland fromula,client's 24hr IV fluid relacement should be: A. 6,080 ml B. 9,120 ml C. 12,160 ml D. 15,180 ml C. The Parkland Formula is 4 ml x kg x TBSA=24hr fluid req, or 4 x 76 x 40 = 12160 ml
On 3rd post-burn day, RN finds that client's hrly urine output is 26 ml.RN should continue to assess client & notify doc for an order to: A.Decrease rate of IV infusion B.Change type of IV fluid being admin C.Chnage urinary cath D.^ rate of IV infusion D. The urinary output should be maintained b/t 30-50 l/hr. First action should be to ^ IV rate to prevent ^ acidosis
Jewish client requires grafting to promote burn healing.Which graft is most likely to be unacceptable to client? A.Isograft B.Autograft C.Homograft D.Xenograft D.Xenografts are taken from nonhuman sources. Most common sources are porcine,or pigskin, which would be offensive to Jews and Muslims.
During rehab phase, client's burns become infected with pseudomonas.The topical dressing most likely to be ordered? A.Silver sulfadiazine(Silvadene) B.Poviodine(Betadine) C.Mafenide acetate(Sulfamylon) D.Silver nitrate C. Sulfamylon is effective in treating wounds infected with pseudomonas.Client should receive pain medication prior to dressing changes b/c med produces burning sensation when applied to wound.
The CVP reading of a client w/ partial-thickness burns is 6 mmH2o.The RN recognizes that the client: A.Needs additional fluids B.Has a normal CVP reading C.May show signs of CHF D.Would benefit from a diuretic B. Normal CVP reading is 5-12 mmH2O
The physician has prescribed Protronix(pantoprazole) for a client w/burns. The nurse recognizes that the medication will help prevent the development of: A.Curling's ulcer B.Myoglobin C.Hyperkalemia D.Paralytic ileus A. Curling's ulcer, a stress ulcer, is a common occurence in client's w/ burns.Protronix, a proton pump inhibitor, is effective in preventing ulcer formation.
The nurse has just completed the dressing change for a client w/ burns to the lower legs & ankles. The nurse should place the client's ankles in which position? A.Internal rotation B.Abduction C.Dorsiflexion D.Hyperextension C. Placing the ankles in dorsiflexed position helps preveny contractures
Thermal burns are from_______ flames, scalds, heat
Non-thermal burns are from__________ electricity, chemicals, radiation
What do you give and what do you not give in 1st 24hrs after a burn? You give IV fluids, you do not give K+
What are some factora affecting the severity of a burn injury? % of TBSA burned, age, location, other diseases, depth of injuries sustained
What is important for the nurse to determine in the patients history? When the client received their Tetanus booster
Signs & symptoms of smoke inhalation Hoarse voice, singed nasal hairs, brassy cough, erythema of pharynx, black sputum
What happens in the first phase? Capillaries dilate-increased capilaary permeability-plasma to interstitial fluid shifting-edema-blistering-hyperkalemis=a-cardiac arrest-low BP-hypovolemia-Acute renal failure
What happens during the second phase? Interstitial to plasma fluid shifting-increased blood volume-increased urine output-hypokalemia-circulatory overload-CHF
What burn % requires hospitalization and rehabilitation and are classified as a major injury? 10% for a child, 15-20% for an adult
Burn diagnostic tests (5) electrolytes, CBC, serum chemistries, ABG, carboxyhemoglobin
Treatment for carbon monoxide poisoning Give 100$% oxygen
What is medical management in burns? IV therapy(RL)-insert foley(to monitor output_-insert NG tube(decompress to remove gas-paralytic ileus)-Morphine sulfate-Tetanus prophylaxis
Managing burns in acute phase 10 days to months-prevent infection-prevent other complications(HF, contractures, ARF, paralytic ileus, Curling ulcer
What are hypoxemia, hypoxia, ischemia? lack of oxygen
What other nursing interventions are necessary with burn injuries? Debride wound-prevent infection-apply topical ABT/drugs-change drgs BID-remove eschar(excherotomy)to ^ peripheral circ-open/closed wound care-proper position & ROM excer-spec beds-skin graft to F-Thick burns-immobilize graft site-antacid or PPI(ulcer)
ATB burn medication special notes mefenide(Sulfamylon)-is painful to applysilver sulfadiazene(Silvadene)-stains skin
Types of skin grafts(3) Autograft-from same personHeterograft/allograft-from another personcadavar/heterograft/xenograft-from another species(pig, cow)
Created by: kpadilla