Nokea
A client is brought to the emergency department after sustaining a serious 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
Correct Answer: D
Rationale: 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.
You may also like to solve these questions
Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply.
- A. Lessen potential for infection
- B. Maximizes fluid loss
- C. Promotes granulation of tissue
- D. Covers the unstractiveness of the wound
- E. Sows regeneration of tissue
- F. Diminishes pain
Correct Answer: A,F
Rationale: Skin substitutes provide a temporary covering of the burn area and lessen the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.
Skin grafts are necessary for what type of burn?
- A. Superficial
- B. Superficial partial thickness
- C. Full-thickness
- D. First degree
Correct Answer: C
Rationale: 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.
A young child is being evaluated for an 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
Correct Answer: B
Rationale: The Lund and Browder method divides the 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.
Which is the primary reason for placing a client in a horizontal position while smothering flames that are present?
- A. To prevent collapse and further injuries
- B. To keep fire and smoke from airway
- C. To extinguish flames more quickly
- D. To promote blood flow to the brain and vital organs
Correct Answer: B
Rationale: 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. The stop, drop, and roll method is a quick and efficient means to extinguish flames. If hypovolemic shock occurs, lowering the head will assist in promoting blood flow to the head.
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. Escharostomy
- D. Ventilator assisted breathing
Correct Answer: C
Rationale: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharostomy 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.