Nokea
A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?
- A. To increase the effectiveness of the skin graft.
- B. Prevention of infection and promote healing.
- C. Promoting suppuration of the wound.
- D. Promoting movement in the affected area.
Correct Answer: B
Rationale: Débridement is the removal of damaged tissue and cellular debris from a wound or burn to prevent infection and to promote healing. Debridement does not increase the effectiveness of the skin graft, promote wound suppuration or movement.
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Which may indicate a malignant melanoma in a nevus on a patient's arm?
- A. Even coloring of the mole
- B. Decrease in size of the mole
- C. Irregular border of the mole
- D. Symmetry of the mole
Correct Answer: C
Rationale: Any change in color, size, or texture and any bleeding or pruritus of a nevus deserves investigation. A malignant melanoma is a cancerous neoplasm in which pigment cells or melanocytes invade the epidermis, dermis, and sometimes the subcutaneous tissue.
The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
- A. Increase the IV rate and monitor for burn shock.
- B. Monitor for signs of seizure activity.
- C. Assess for signs of fluid overload.
- D. Raise the foot of the bed and apply blankets.
Correct Answer: C
Rationale: As the blood volume increases, the cardiac output increases to increase renal perfusion. The result includes diuresis. However, a great risk for the patient includes fluid overload because of the rapid movement of fluid back into the intravascular space. Burn shock occurs from hypovolemia in the first 72 hours of a burn injury. Seizures are not associated with the burn injury. Raising the foot of the bed would not be of value in this situation.
A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and report spain and pruritus. For which reason will the nurse use a Woods lamp?
- A. To dry out the lesions.
- B. To reduce the pruritus.
- C. To kill the fungus.
- D. To cause fluorescence of the infected hairs.
Correct Answer: D
Rationale: Tinea capitis is commonly known as ringworm of the scalp. Microsporum audouinii is the major fungal pathogen. The use of the diagnostic Woods lamp causes the infected hairs to turn a brilliant blue green. The Woods lamp does not dry out lesions, reduce pruritus or kill fungus.
A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
- A. Within 12 hours after burn trauma
- B. 24 to 36 hours after burn trauma
- C. 36 to 48 hours after burn trauma
- D. 48 to 72 hours after burn trauma
Correct Answer: A
Rationale: In a burn injury, usually the greatest fluid loss occurs within the first 12 hours.
Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?
- A. My skin is cleared up. I don't think I need the medication anymore.'
- B. Cellulitis can come back at any time.'
- C. If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.'
- D. Cellulitis is contagious.'
Correct Answer: A
Rationale: The entire amount of antibiotic medication should be completed even if the symptoms have abated to ensure the eradication of the infectious agent. Cellulitis can return if untreated or undertreated. Washing wounds with soap and water can prevent many infections, but this is not related to the discussion of antibiotics. Cellulitis can spread, however this is not related to the discussion of antibiotics.