Nokea
A patients burns have required a homograft. During the nurses most recent assessment, the nurse observes that the graft is newly covered with purulent exudate. What is the nurses most appropriate response?
- A. Perform mechanical debridement to remove the exudate and prevent further infection.
- B. Inform the primary care provider promptly because the graft may need to be removed.
- C. Perform range of motion exercises to increase perfusion to the graft site and facilitate healing.
- D. Document this finding as an expected phase of graft healing.
Correct Answer: B
Rationale: Purulent exudate indicates possible graft infection, necessitating prompt provider notification for potential graft removal. Debridement or exercises are inappropriate, and infection is not an expected healing phase.
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A patient is brought to the emergency department from the site of a chemical fire, where he suffered a burn that involves the epidermis, dermis, and the muscle and bone of the right arm. On inspection, the skin appears charred. Based on these assessment findings, what is the depth of the burn on the patients arm?
- A. Superficial partial-thickness
- B. Deep partial-thickness
- C. Full partial-thickness
- D. Full-thickness
Correct Answer: D
Rationale: A full-thickness burn extends through the epidermis, dermis, and into underlying tissues like muscle or bone, appearing charred and painless due to nerve destruction. Superficial partial-thickness affects the epidermis, deep partial-thickness involves the deeper dermis, and full partial-thickness is not a recognized term.
A patient is brought to the emergency department with a burn injury. The nurse knows that the first systemic event after a major burn injury is what?
- A. Hemodynamic instability
- B. Gastrointestinal hypermotility
- C. Respiratory arrest
- D. Hypokalemia
Correct Answer: A
Rationale: Hemodynamic instability occurs first due to capillary leakage, causing fluid shifts and hypovolemia. GI hypermotility, respiratory arrest, or hypokalemia are not initial events.
A nurse is performing a home visit to a patient who is recovering following a long course of inpatient treatment for burn injuries. When performing this home visit, the nurse should do which of the following?
- A. Assess the patient for signs of electrolyte imbalances.
- B. Administer fluids as ordered.
- C. Assess the risk for injury recurrence.
- D. Assess the patients psychosocial state.
Correct Answer: D
Rationale: Psychosocial assessment is critical during rehabilitation, as burn recovery poses psychological challenges like PTSD or depression. Electrolyte imbalances are rare in this phase, fluids are not typically administered, and burn recurrence is unlikely.
A patient experienced a 33% TBSA burn 72 hours ago. The nurse observes that the patients hourly urine output has been steadily increasing over the past 24 hours. How should the nurse best respond to this finding?
- A. Obtain an order to reduce the rate of the patients IV fluid infusion.
- B. Report the patients early signs of acute kidney injury (AKI).
- C. Recognize that the patient is experiencing an expected onset of diuresis.
- D. Administer sodium chloride as ordered to compensate for this fluid loss.
Correct Answer: C
Rationale: Increased urine output 72 hours post-burn indicates the onset of diuresis as capillaries regain integrity, shifting fluid back to the intravascular space. This is expected, not indicative of AKI or requiring fluid reduction or sodium administration.
A nurse is developing a care plan for a patient with a partial-thickness burn, and determines that an appropriate goal is to maintain position of joints in alignment. What is the best rationale for this intervention?
- A. To prevent neuropathies
- B. To prevent wound breakdown
- C. To prevent contractures
- D. To prevent heterotopic ossification
Correct Answer: C
Rationale: Maintaining joint alignment prevents contractures, a common complication of burns due to tissue shortening. It does not primarily prevent neuropathies, wound breakdown, or ossification.