Nokea
Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply.
- A. Lessen potential for infection
- B. Maximizes fluid loss
- C. Promotes granulation of tissue
- D. Covers the unstractiveness of the wound
- E. Sows regeneration of tissue
- F. Diminishes pain
Correct Answer: A,F
Rationale: Skin substitutes provide a temporary covering of the burn area and lessen the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.
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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.
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?
- A. Endotracheal tube insertion
- B. Tracheostomy
- C. Escharostomy
- D. Ventilator assisted breathing
Correct Answer: C
Rationale: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharostomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.
A client with a burn injury is in acute stress. The nurse knows that which of the following complications is prone to develop in this client?
- A. Anemia
- B. Gastric ulcers
- C. Hyperthyroidism
- D. Cardiac arrest
Correct Answer: B
Rationale: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
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.
What is a benefit(s) that supports the use of a closed method wound care in the management of a client with burns? Select all that apply.
- A. Provides a drier environment
- B. Promotes heat loss
- C. Creates microbial barrier
- D. Prevents exudate accumulation
- E. Reduces pain during position changes
- F. Promotes slower healing
Correct Answer: C,E
Rationale: The closed method is the preferred method of wound management for most burn victims. It creates a microbial barrier and applies direct pressure to the wound, which reduces pain during position changes. Closed wound management provides a moist environment while reducing heat loss and evaporation, which facilitates faster healing. Frequent dressing changes may be required if the wound is infected or when there is significant exudate accumulation.