NCLEX Questions On Burn Injury Nursing Management

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level. the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal. but not to the same degree of severity. and would be expected in the emergent phase after a burn injury.

Although a return to pre-burn functional levels is rarely possible. burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical. social. and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

During the fluid shift of the emergent period. blood flow to the kidney may not be adequate for glomerular filtration. As a result. urine output is greatly decreaseD. Foul-smelling discharge does not occur during the emergent phase and blood pressure is usually low. Pain does not occur with deep full-thickness burns.

During the emergent phase. fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity. the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury. causing decreased tissue perfusion and necessitating the intervention of an escharotomy. Chemical burns do not cause inhalation injury and a disrupted breathing pattern. Disturbed body image and disuse syndrome can develop. However. these are not priority diagnoses at this time.

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status.

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body. causing infection of a previously uninfected area. Although all techniques listed can help reduce the risk for infection. only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination.

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive. newly healed skin and grafts from sun exposure. this is not the purpose for wearing the mask. The pressure garment will not alter the risk for infection.

Gentamicin does not stimulate pain in the wound. The small. pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored.

Clients should request food whenever they think that they can eat. not just according to the hospital’s standard meal schedule. The nurse needs to work with a nutritionist to provide a high-calorie. high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications.