Burns

Sunday, April 21, 2019 10:44 PM

B Breathing (oxygen, intubation

U Urine output (hyperkalemia)
R Resuscitation of fluid (LR's)
N Nutrition (high cal/protein)
S Shock (hypovolemic)

Signs/Symptoms
Burns, pain, swelling
Dizziness
Loss of consciousness
Hypotension/shock
Airway compromise/distress
Hoarseness/wheezing

1st Degree • Red

(superficial) • Blanching
• Mild/moderate
pain
• Sunburns or
minor
heat/friction
2nd Degree • Blistered
(partial • Moist
thickness) • Painful

3rd Degree • Destruction of

(full thickness epidermis,
injury) dermis and
subcut tissue
• Dry
• Leathery
• Minimal pain
 epidermis,
injury) dermis and
subcut tissue
• Dry
• Leathery
• Minimal pain
4th Degree • Life threatening
• Needs
debridement
• Into muscle and
bone
• No pain

Practice Quiz:

1. A client who is admitted after a thermal burn injury has

the following vital signs: blood pressure, 70/40; heart
rate, 140 beats/min; respiratory rate, 25/min. He is pale
in color and it is difficult to find pedal pulses. Which
action will the nurse take first?
a. Begin IV fluids
b. Check pulses
c. Obtain CBC
d. Obtain ECG
2. A client who was burned has crackles and a respiratory rate
of 40/min, and is coughing up blood-tinged sputum. What
action will the nurse take first?
a. Administer digoxin
b. Perform chest physio
c. Monitor U/O
d. Place client in upright position
3. How will the nurse position a client with a burn wound to
the posterior neck to prevent contractures?
a. Have client turn head side to side
b. Keep client supine
c. Semi-fowlers with arms elevated
d. Place towel roll under clients neck
4. On assessment, the nurse notes that the client has burns
inside the mouth and is wheezing. Several hours later, the
wheezing is no longer heard. What is the nurse’s next
action?
a. Document finding s
b. Loosen dressings on chest
c. Raising HOB
d. Prepare for intubation
5. Ten hours after the client with 50% burns is admitted, her
 action?
a. Document finding s
b. Loosen dressings on chest
c. Raising HOB
d. Prepare for intubation
5. Ten hours after the client with 50% burns is admitted, her
blood glucose level is 7.8 mmol/L. What is the nurse’s best
action?
a. Document findings
b. Obtain family history of DM
c. Repeat accu check
d. Stop IV fluids with dextrose
6. The client has a large burned area on the right arm. The
burned area appears pink, has blisters, and is very
painful. How will the nurse categorize this injury?
a. Full thickness
b. Partial thickness-superficial
c. Partial thickness-deep
d. Superficial
7. The client has experienced an electrical injury of the
lower extremities. Which are the priority assessment data
to obtain from this client?
a. Current ROM of extremities
b. Heart rate and rhythm
c. RR and pulse ox reading
d. Orientation to time, place and person
8. The client who is burned is drooling and having difficulty
swallowing. Which action will the nurse take first?
a. Assess LOC and pupillary response
b. Ascertains the time food or liquid last consumed
c. Auscultate breath sounds over the trachea and mainstem
bronchi
d. Measure abdominal girth and auscultate bowel sounds
9. The client with a full-thickness burn is being discharged
to home after a month in the hospital. His wounds are
minimally opened and he will be receiving home care. Which
nursing diagnosis has the highest priority?
a. Acute pain
b. Deficient diversional activity
c. Impaired adjustment
d. Imbalanced nutrition: less than
10. The client with open burn wounds begins to have diarrhea.
The client is found to have a below-normal temperature,
with a white blood cell count of 4000/mm3. Which is the
nurse’s best action?
a. Continue to monitor
b. Increase the temp in room
10. The client with open burn wounds begins to have diarrhea.
The client is found to have a below-normal temperature,
with a white blood cell count of 4000/mm3. Which is the
nurse’s best action?
a. Continue to monitor
b. Increase the temp in room
c. Increase the rate of IV
d. Prepare for workup for sepsis