Certified Exam Guide: Caring for Burn Clients (Updated 2024/2025), Exams of Nursing

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CERTIFIED EXAM STUDY GUIDE ON CARING

FOR CLIENTS WITH BURNS

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CLIENTS WITH BURNS

BEST EXAM STUDY GUIDE UPDATED 2024/

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation? A) The client's heart rate is rapid and regular. B) The client's urinary output is 0.3 to 0.5 mL/ kg/hour. C) The client's breathing is unlabored, and skin is clammy. D) The client is alert and conscious. Ans: B Feedback: Successful fluid resuscitation is gauged by a urinary output of 0.3 to 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

Which of the following actions should a nurse perform to help reduce the accumulation of debris within the burn wound? A) Use powder-free sterile gloves. B) Use topical antimicrobial medications. C) Use cold compresses or sponges. D) Use sterilized gauze swaps. Ans: A Feedback: The healthcare team should wear powder-free sterile gloves when handling the burn wound to reduce the accumulation of debris within the wound that may complicate the healing. After the wound has been cleansed, topical antimicrobial medications are used to minimize the risk of infection. The particles or fiber from cold compresses, sponges, or sterilized gauze swaps may add to the accumulation` of debris if used on a burn wound.

CLIENTS WITH BURNS

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Skin grafts are necessary for which of the following burns? A) Superficial B) Superficial partial thickness C) Full thickness D) First degree Ans: C Feedback: Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.

Which zone consists of the area where the injury is most severe and deepest? A) Coagulation B) Stasis C) Hyperemia D) Necrosis Ans: A Feedback: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury, where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.

Which type of debridement occurs when nonliving tissues sloughs away from uninjured tissues? A) Mechanical B) Natural C) Enzymatic D) Surgical Ans: B Feedback:

CLIENTS WITH BURNS

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Natural debridement is accomplished when nonliving tissue sloughs away from uninjured tissue. Mechanical debridement occurs when dead tissue adheres to dressings or is detached during cleaning. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses forceps and scissors during dressing changes or wound cleaning.

Which of the following skin substitutes is a nylon-silicone membrane coated with a protein derived from pig tissue? A) Mederma B) Integra C) TransCyte D) Biobrane Ans: D Feedback: Biobrane is a nylon-silicone membrane coated with a protein derived from pig tissue. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane: one is a synthetic epidermal layer, and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. TransCyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.

Which type of skin graft is more comparable in appearance to normal skin? A) Lace graft B) Full-thickness graft C) Slit graft D) Split-thickness graft Ans: B Feedback:

CLIENTS WITH BURNS

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After a burn, fluid from the body moves toward the burned 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 tissues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that were destroyed during the burn can result in acute renal failure. Destruction of the skin barrier results in colonization of bacteria and can lead to life-threatening infection in days following the burn.

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? A) Risk for Impaired Gas Exchange B) Acute Pain C) Risk for Infection D) Alteration in Tissue Perfusion Ans: A Feedback: 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.

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%

CLIENTS WITH BURNS

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C) 27%

D) 36%

Ans: D Feedback: 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.

When the area of burn is irregular in shape and is 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? A) Rule of nines B) Use client's palm size C) Parkland formula D) Lund and Browder burns assessment Ans: B Feedback: 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 Browder burns assessment provides a more precise estimate for determining TBSA that is burned and is especially more specific in children. The rule of nines quantitates burns that involve entire sections of the body, not scattered burns.

CLIENTS WITH BURNS

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Following a burn, the nurse understands that the focused management of which burn zone is of greatest concern? A) Zone in burn center B) Zone of coagulation C) Zone of hyperemia D) Zone of stasis Ans: D Feedback: The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.

An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior? A) The client is in hypovolemic shock. B) The client has experienced extensive full- thickness burns. C) The paramedic administered high doses of opioids during transport. D) The client has experienced partial-thickness burns. Ans: B Feedback:

CLIENTS WITH BURNS

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In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opioids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.

A young child is being evaluated for 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 Ans: B Feedback: The Lund and Browder method divides 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.

After being exposed to smoke and flames from a house fire, which assessment finding is most important in determining care of the client? A) Presence of soot around nasal passages B) Fracture of the fibula with displacement C) Elevation of blood pressure and heart rate D) Partial-thickness burns to hands and wrists

CLIENTS WITH BURNS

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A manufacturing plant has exploded, and the nurse is assigned to triage burn victims as they arrive to the hospital. Which is the most important question for the nurse to ask prior to the arrival of victims? A) “Are the victims suffering from thermal burns?” B) “How many victims are anticipated for transport?” C) “Are the burns associated with chemicals used in the plant?” D) “Are any of the victims expected to have electrical burns?” Ans: C Feedback: If the victim has sustained chemical burns, the chemicals must be removed from the skin to prevent burns to others, including the triage nurse and emergency staff. Thermal and electrical burn victims do not require special handling considerations. The number of victims expected is not a significant issue for the triage nurse but rather for the external disaster team dispatch personnel.

The nurse knows that inflammatory response following a burn is proportional to the extent of injury. Which factor presents the greatest impact on the ability to modify the magnitude and duration of the inflammatory response in a client with a burn? A) Age B) Weight C) Preexisting conditions D) Family history Ans: C Feedback:

CLIENTS WITH BURNS

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Preexisting disease disorders including trauma and infections can modify the inflammatory response and movement of fluid from the vascular to the interstitial space. Age, weight, and family history are not as significant in the inflammatory response following a burn.

Which is the primary reason for placing a client in a horizontal position while smothering flames are present? A) To prevent collapse and further injuries B) To keep fire and smoke from airway C) To distinguish flames more quickly D) To promote blood flow to the brain and vital organs Ans: B Feedback: The primary reason the client is placed in a horizontal position while smothering flames is to prevent the fire, hot air, and smoke from rising toward the head and entering the respiratory passages. Stop, drop, and roll method is a quick efficient means to distinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.

Initial first aid rendered at the scene of a fire includes preventing further injury through heat exposure. Which intervention could contribute to tissue hypoxia and necrosis and therefore should be avoided? A) Removal of clothing B) Irrigation of the wound C) Application of ice D) Removal of hair Ans: C Feedback:

CLIENTS WITH BURNS

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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.

A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client? A) Endotracheal tube insertion B) Tracheostomy C) Escharotomy D) Ventilator assisted breathing Ans: C Feedback: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharotomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.

The spouse of a victim, who was struck by lightning, asks the nurse why the areas involved seems so small but the damage is extensive. Which is the best explanation from the nurse? A) Electrical burns usually follow an internal path.

CLIENTS WITH BURNS

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B) Lightning is higher in voltage than electricity. C) The skin is a good conductor of electricity. D) Moisture intensifies the damage inflicted. Ans: A Feedback: Electrical current follows the path of less resistance. Because the skin is the most resistant organ, the current follows nerves, blood vessels, and muscles, causing organ damage along the way. Lightning is high- voltage electricity. Presence of water acts as a conductor of electrical current.

Which of the following are benefits that support the use of a closed method wound care in the management of a client with burns? Select all that apply. A) Provides a drier environment B) Promotes heat loss C) Creates antimicrobial barrier D) Prevents exudate accumulation E) Discourages hypertrophic scarring F) Promotes slower healing Ans: C, E Feedback: The closed method is the preferred method of wound management for most burn victims. It creates a microbial barrier and applies direct pressure to the wound, which discourages hypertrophic scarring. Closed wound management provides a moist environment while reducing heat loss and evaporation, which facilitates faster healing. Frequent dressing changes may be required if the wound is infected or when there is significant exudate accumulation.

CLIENTS WITH BURNS

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Silver sulfadiazine (Silvadene) does not penetrate so should be used on clean, debrided burn areas. Discharge instructions should include the need to remove old ointment prior to application of new. Silver sulfadiazine (Silvadene) is considered a closed method of treatment and does not require additional dressing application. Silver sulfadiazine (Silvadene) should be applied sparingly using a sterile glove or applicator.

Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material? A) “This graft contains material obtained from a cow.” B) “This graft will not become a permanent part of my skin.” C) “This graft was applied with a spray gun.” D) “This graft was harvested from another human.” Ans: B Feedback: A xenograft, such as Oasis, is a temporary cover that will be rejected in days to weeks and will need to be replaced or removed at that time. A porcine graft originates from a pig. Autologous skin cell isolation grafting requires a 5 × 5 cm sample of skin that is separated and sprayed on the wound. Cadaver skin and or stem cells from umbilical cord blood are grafting material that is harvested from another human.

CLIENTS WITH BURNS

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The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts? A) Less scarring B) Less discomfort C) Speeds healing D) Rejection is unlikely. Ans: D Feedback: In an autograft slit graft, the skin is harvested from the client's buttocks or thighs. Rejection is less likely with this type of graft because the donor and recipient are the same. There will be scarring at both the donor and recipient sites, and added discomfort is associated from the donor site. Because the slit graft is expanded through a meshing device, the scarring will appear as a mesh. Healing is delayed due to need for two wounds.