Nokea
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.
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The nurse is caring for several clients who have burns. Which of the following persons with burns has the poorest prognosis?
- A. A 20-year-old with second- and third-degree burns over 60% of the body
- B. An 80-year-old with second- and third-degree burns over 50% of the body
- C. A 35-year-old with second- and third-degree burns over 60% of the body
- D. A 2-year-old with second- and third-degree burns over 30% of the body
Correct Answer: B
Rationale: The 80-year-old with burns over 50% has the poorest prognosis due to age-related factors, such as reduced physiological reserve and difficulty managing fluid shifts, increasing mortality risk.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority?
- A. High risk for infection.
- B. Ineffective coping.
- C. Impaired physical mobility.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Extensive burns increase infection risk due to loss of skin barrier; this is the priority. Coping, mobility, and knowledge are secondary in acute burn care.
What images will a client with macular degeneration most likely describe seeing?
- A. Objects that are close to the face
- B. Objects that are clear distance
- C. Objects that are in outer peripheral fields
- D. Objects that are in the central field of vision
Correct Answer: C
Rationale: Macular degeneration spares peripheral vision, affecting central vision.
The nurse is caring for a client one (1) day postoperative for facial reconstruction. Which intervention should the nurse implement?
- A. Provide all activities of daily living.
- B. Allow the client to voice fears and concerns.
- C. Monitor nutritional food and fluid intake.
- D. Assess signs and symptoms of infection.
Correct Answer: D
Rationale: Assessing for infection is critical post-facial reconstruction to prevent complications. ADL provision, voicing concerns, and nutrition are secondary.
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.