Detailed Answer Key

RN 231 Quiz 4_Cloned_Assessment 1

1.A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns

of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at

greatest risk for

A. airway obstruction.

Rationale:Burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat as

well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing

measures to maintain a patent airway should take priority in this client's care.

B. infection.

Rationale:Although prevention of infection is an important aspect of burn care throughout hospitalization

and treatment, there is a greater initial priority for this client.

C. fluid imbalance.

Rationale:Although adequate fluid replacement is an important aspect of burn care throughout the acute

phase of burn treatment, there is a greater initial priority for this client.

D. paralytic ileus.

Rationale:Although paralytic ileus may occur during the acute phase aspect of burn care and may require

nasogastric suctioning, there is a greater initial priority for this client.

2.A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities

and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the

following nursing statements is appropriate?

A. "Large incisions will be made in the eschar to improve circulation."

Rationale:An escharotomy is a surgical incision made to release pressure and improve circulation in a part

of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that

encircle a body part, such as an arm or the chest, can cause swelling and tightness in the

affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue

allows the skin to expand, reduces tightness and pressure, and improves circulation.

B. "I can call the doctor back here if you want me to."

Rationale: This is a nontherapeutic response that defers the client's concern and puts it on hold.

C. "A piece of skin will be removed and grafted over the burned area."

Rationale:A surgical procedure in which a piece of skin from one area of the client's body is transplanted to

another area is called a skin graft.

D. "Dead tissue will be surgically removed."

Rationale: Debridement is the surgical removal of dead tissue.

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Detailed Answer Key

RN 231 Quiz 4_Cloned_Assessment 1

3.A group of college students was attending a weekend football rally when one of the students stumbled and fell into

the bonfire. Although several friends quickly intervened, the client sustained partial-thickness burns to both lower

legs, chest, and both forearms. Which of the following is the priority nursing action when the client is brought into

the emergency room?

A. Cover the burned area with sterile gauze.

Rationale:Infection is one of the leading causes of death with burn injuries. Because the integrity of the

skin is breeched, it is vital to cover all burned areas with sterile gauze; however, this is not the

priority concern at this time.

B. Inspect mouth for signs of inhalation injuries.

Rationale:Since the client sustained burns to the chest, there is a possibility that flames and smoke from

the client's burning clothes could have caused an inhalation injury. The nurse should inspect the

mouth and throat for soot and swelling. Using the airway, breathing, circulation (ABC)

priority-setting framework, this is the priority concern at this time.

C. Administer intravenous pain medication.

Rationale:Because of the large percentage of burned area, this client will experience high levels of pain,

since partial-thickness burns expose fragile nerve endings. Large doses of intravenous

morphine or other narcotic analgesics will likely be needed for adequate pain control. Despite

the fact that pain is an important issue, it is not the priority concern at this time.

D. Draw blood for a complete blood cell (CBC) count.

Rationale:Burn injuries, such as this one, that exceed 20% of body surface area are considered major

burns, which affect the client’s metabolism, hemodynamic balance, and immune system. In the

early stage of burns, increased capillary permeability allows sodium to enter cells while

potassium leaks out, resulting in hyponatremia and hyperkalemia. An altered osmotic gradient

and loss of intravascular fluid causes elevated hematocrit levels. Initial lab studies are important

to create a baseline because of these systemic effects of burns. Those labs would include a

CBC, electrolytes, BUN, creatinine, and blood glucose. While it is important to establish baseline

data, it is not the priority concern at this time.

4.A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and

arms. Using the rule of nines the nurse should document burns to which percentage of the client’s total body

surface area (TBSA)?

A. 9 percent

Rationale:Each arm represents 9% of the client’s TBSA.

B. 18 percent

Rationale:Each leg represents 18% of the client’s TBSA.

C. 36 percent

Rationale:Both legs represent 36% of the client’s TBSA.

D. 54 percent

Rationale:

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Detailed Answer Key

RN 231 Quiz 4_Cloned_Assessment 1

Each arm represents 9% of the client’s TBSA and each leg represents 18% of the client’s TBSA

totalling 54%.

5.A nurse is caring for a client who has full-thickness burns all over 75% of his body. Which of the following methods

is appropriate to accurately monitor the cardiovascular system?

A. Auscultate cuff blood pressure.

Rationale: Clients who have a large percentage of burned body surface area often do not have an area for

the nurse to safely apply the cuff. Additionally, cuff blood pressures are affected by peripheral

vascular changes.

B. Palpate pulse pressure.

Rationale: Clients who have a large percentage of burned body surface area require critical care and

accurate monitoring. Palpation of pulse pressure does not provide data to detect subtle changes

in the cardiovascular system.

C. Obtain a central venous pressure.

Rationale: Clients who have a large percentage of burned body surface area require critical care and

accurate monitoring. The central venous pressure provides important data but does not

accurately detect changes in left heart pressure.

D. Monitor the pulmonary artery pressure.

Rationale: Clients who have a large percentage of burned body surface area require critical care and

accurate monitoring. The pulmonary artery pressure provides an accurate assessment of the

cardiovascular system by detecting changes in left heart pressure which can detect possible

development of pulmonary edema.

6.A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following should

the nurse include to provide emotional support?

A. Assign assistive personnel to keep his room neat and clean.

Rationale: This intervention is important for infection control but does not address the client’s need for

emotional support.

B. Rotate nursing staff so he can have varied interactions.

Rationale: This intervention inhibits the development of a trusting, nurse-client relationship which is an

important component of providing emotional support.

C. Talk with him during wound care.

Rationale: Talking with the client while providing care assists in the development of the nurse-client

relationship and demonstrates caring.

D. Keep family members aware of his condition.

Rationale:

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