Nokea
The client is admitted with full-thickness burns to the forearm. Which is the most accurate interpretation made by the nurse?
- A. The wound will take up to 3 weeks to heal.
- B. Pain management will be a challenge.
- C. Skin grafting will be necessary.
- D. Ligaments, tendons, muscles, and bone are not involved.
Correct Answer: C
Rationale: In a full-thickness burn, all layers of the skin are destroyed and will result in the need for skin grafts. Full-thickness burns are painless. A deep partial-thickness burn may take 3 or more weeks to heal. In the most serious full-thickness burns, ligaments, tendons, muscles, and bone may be involved.
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A nurse is monitoring the effectiveness of fluid resuscitation in a client who is being treated for burns. What assessment would indicate the success of the fluid resuscitation?
- A. The client's heart rate is rapid and regular.
- B. The client's urinary output is 0.5 to 1 ml/kg/hour.
- C. The client's breathing is unlabored, and skin is clammy.
- D. The client is alert and conscious.
Correct Answer: B
Rationale: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 ml/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
- A. Risk for Impaired Gas Exchange
- B. Acute Pain
- C. Infection Risk
- D. Altered Tissue Perfusion
Correct Answer: A
Rationale: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.
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.
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
- A. Myoglobin in the urine
- B. Increase in antidiuretic hormone (ADH)
- C. Elevation of blood glucose levels
- D. Hypermatremia
Correct Answer: A
Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
A client brought to the emergency department has been exposed to smoke and flames from a house fire. What assessment finding is most important to the nurse in determining care of the client?
- A. Presence of soot around nasal passages
- B. Fracture of the fibula with displacement
- C. Elevation of blood pressure and heart rate
- D. Partial-thickness burns to hands and wrists
Correct Answer: A
Rationale: If the client has soot or evidence of carbon about the nasal passages, the nurse should anticipate respiratory difficulties. Edema and swelling of the internal airways may not be present initially but can progress quickly. Elevation of heart rate without hypotension is not as significant. Fracture to any bone as well as care of burns should be managed once the airway, breathing, and circulation are assessed and managed.