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An electrician was wearing a glove that had a hole in it when he grabbed a 'hot' wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially?
- A. Dress the entrance and exit wounds
- B. Check respirations and pulse rate
- C. Remove clothing from the burned area
- D. Roll him in a blanket
Correct Answer: B
Rationale: Checking respirations and pulse rate is the initial action to assess for life-threatening complications, such as cardiac arrhythmias, common in electrical burns.
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The client is scheduled for application of a cadaver homograph to a burn on the forearm. Which comment by the client demonstrates an accurate understanding of this procedure?
- A. The graft donor site from my right upper thigh shouldn't take too long to heal.
- B. I know this graft will only be a temporary measure to protect and help heal my arm.
- C. I am glad that there is no risk of me getting a blood-borne disease with this type of graft.
- D. If this graft doesn't permanently take, then I'll need to select another graft donor site.
Correct Answer: B
Rationale: A cadaver skin graft is a type of temporary graft, also called a biological dressing, and it is used to protect the damaged skin and promote healing and epithelialization. A cadaver skin graft does not use the client's own skin, so there is no donor site. There is a risk of transmitting blood-borne infections with cadaver grafts. The graft is not permanent, so no further donor site selection is needed.
The nurse is caring for clients with second- and third-degree burns. Which medication should the nurse plan to apply topically to treat bacterial and yeast infections?
- A. Bismuth subsalicylate
- B. Gold sodium thiomalate
- C. Silver sulfadiazine
- D. Arsenic trioxide
Correct Answer: C
Rationale: Silver sulfadiazine (Silvadene) is a topical anti-infective agent for prevention and treatment of wound infection in second- and third-degree burn clients. Bismuth subsalicylate (Kaopectate) is an antidiarrheal medication. Gold sodium thiomalate (Aurolate) is used to treat rheumatoid arthritis resistant to conventional therapy. Arsenic trioxide (Trisenox) is an antineoplastic.
When developing nursing care plans, the nurse is careful to classify which type of wound as a chronic wound?
- A. A gunshot wound with tissue damage
- B. A slow-healing diabetic foot ulcer
- C. A stage I pressure ulcer on the coccyx
- D. A 7-day-old infected surgical wound
Correct Answer: B
Rationale: Diabetic foot ulcers heal slowly, classifying them as chronic.
The nurse is assessing the client for possible scabies infestation. Which findings should the nurse expect?
- A. Serosanguineous drainage and fever
- B. Malaise and local edema
- C. Itching and papule-like rash
- D. Macule rash and blisters
Correct Answer: C
Rationale: The most common symptoms of a scabies infestation are itching and papule rash. Serosanguineous drainage and fever or malaise and edema occur with wound infections. Macule rash and blisters may occur with allergic reactions.
After touching a hot oven grate, the client telephones the ED asking for advice for the singed fingers. Which initial statement by the nurse is most appropriate?
- A. Wrap ice in a washcloth and put it on the burn area.
- B. Come to the ED so a doctor can assess your fingers.
- C. Run cool water over the burned area on your fingers.
- D. Apply an antibiotic skin ointment to prevent infection.
Correct Answer: C
Rationale: Ice causes vasoconstriction and can worsen the tissue damage. The nurse should collect additional information before advising that the client be seen in the ED. A first-degree burn ordinarily does not require medical care. Cool water will minimize skin redness, pain, and swelling and limit tissue damage. Applying a skin ointment as an initial intervention can trap heat in the tissues; if it has an oily base, it can prevent healing.