Nokea
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.
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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.
Correct Answer: B
Rationale: 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 cm x 5 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.
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client?
- A. Prevent infection
- B. Fluid resuscitation
- C. Endotracheal tube placement
- D. Strict intake and output
Correct Answer: B
Rationale: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystaloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.
What is a benefit(s) that supports 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 microbial barrier
- D. Prevents exudate accumulation
- E. Reduces pain during position changes
- F. Promotes slower healing
Correct Answer: C,E
Rationale: 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 reduces pain during position changes. 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.
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.
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
Correct Answer: B
Rationale: Full-thickness grafts are more comparable in appearance to normal skin and can tolerate more stress once they become permanently attached to the burn wound. A slit graft (lace graft) is used when the area available as a donor site is limited, as in clients with extensive burns. In a split-thickness graft, the epidermis and a thin layer of the dermis are harvested from the client's skin.