Nokea
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.
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An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: D
Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. None of the other answer choices correctly applies the Rule of nines.
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
- A. Tissue hypoxia
- B. Infection
- C. Renal failure
- D. Hypovolonia
Correct Answer: D
Rationale: After a burn, fluid from the body moves toward the barmed area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the issues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that was destroyed during the burn can result in acute renal failure. Destruction of the skin barrier result in colonization of bacteria and can lead to life-threatening infection in days following the burn.
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.
The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts?
- A. Less scarring
- B. Less discomfort
- C. Speeds healing
- D. Rejection is unlikely.
Correct Answer: D
Rationale: In an autograft slit graft, the skin is harvested from the client's buttocks or thighs. Rejection is less likely with this type of graft because the donor and recipient are the same. There will be scarring at both the donor and recipient sites, and added discomfort is associated from the donor site. Because the slit graft is expanded through a meshing device, the scarring will appear as a mesh. Healing is delayed due to need for two wounds.
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.