ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 : Caring for Clients With Burns Questions
Question 1 of 5
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
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.
Question 2 of 5
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?
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.
Question 3 of 5
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?
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.
Question 4 of 5
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?
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.
Question 5 of 5
During the recovery of an extensive burn, the client is complaining about wearing the tight-fitting custom garment. What is an appropriate response by the nurse?
Correct Answer: C
Rationale: The forming of burn scars can be minimized by the use of pressure dressings and custom-fitted garments that apply continuous pressure. Garments need to be snug in order to be effective. These garments are worn for 23 hours a day and may be prescribed for as long as 2 years. Prevention of infection is not indicated with use.