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    Burns Notes

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    Savanna Chambers
    This document provides information about burns including: - Classification of burns from 1st to 4th degree based on depth of tissue damage. - Signs and symptoms of burns including pain, swelling, dizziness, loss of consciousness, and airway compromise. - A practice quiz with 10 multiple choice questions testing knowledge about burn assessment, management, and priorities of care.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Burns Notes

    Uploaded by

    Savanna Chambers
    103 views4 pages
    This document provides information about burns including: - Classification of burns from 1st to 4th degree based on depth of tissue damage. - Signs and symptoms of burns including pain, swelling, dizziness, loss of consciousness, and airway compromise. - A practice quiz with 10 multiple choice questions testing knowledge about burn assessment, management, and priorities of care.

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    Burns notes

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    This document provides information about burns including: - Classification of burns from 1st to 4th degree based on depth of tissue damage. - Signs and symptoms of burns including pain, swelling, dizziness, loss of consciousness, and airway compromise. - A practice quiz with 10 multiple choice questions testing knowledge about burn assessment, management, and priorities of care.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    103 views4 pages

    Burns Notes

    Uploaded by

    Savanna Chambers
    This document provides information about burns including: - Classification of burns from 1st to 4th degree based on depth of tissue damage. - Signs and symptoms of burns including pain, swelling, dizziness, loss of consciousness, and airway compromise. - A practice quiz with 10 multiple choice questions testing knowledge about burn assessment, management, and priorities of care.

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    © All Rights Reserved
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    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

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