Nokea
A nurse is caring for a client with facial burns who is prescribed the open method treatment. What nursing intervention should the nurse perform?
- A. Administer a cold sponge bath to the client.
- B. Keep the client's room cool and airy.
- C. Place a bed cradle or sheets over the client.
- D. Place the client on a moist linen sheet.
Correct Answer: C
Rationale: The skin of the client with burn is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets should be placed over the client. The room should be kept warm and humidified, not cool and airy. The client should be placed in isolation in a bed with sterile, dry linen. Whirlpool baths are prescribed to loosen the crust, or eschar, which forms over the wound. Sponge baths are not advisable because particles from the sponge may cause accumulation of debris within the burn wound. Moist linen sheets are not placed on clients anymore due to their cooling effect, and they can lead the client to work hard to maintain proper body temperature.
You may also like to solve these questions
Which zone consists of the area where the injury is most severe and deepest?
- A. Coagulation
- B. Stasis
- C. Hyperemia
- D. Necrosis
Correct Answer: A
Rationale: 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.
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 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. Infection Risk
- D. Altered Tissue Perfusion
Correct Answer: A
Rationale: 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.
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse 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
Correct Answer: A
Rationale: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.
What action 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 comppresses or sponges.
- D. Use sterilized gauze swaps.
Correct Answer: A
Rationale: 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 comppresses, sponges, or sterilized gauze swaps may add to the accumulation of debris if used on a burn wound.