Nokea
The nurse is caring for the client with a split-thickness skin graft taken from the thigh to cover a burn on the back. Which intervention should the nurse expect to implement to help reduce the risk of infection at the donor and graft site?
- A. Obtain serial wound cultures of the donor site.
- B. Eliminate plants and flowers in the client's room.
- C. Use clean technique for all wound care procedures.
- D. Administer a continual low dosage of an IV antibiotic.
Correct Answer: B
Rationale: Pseudomonas has been found in plants and flowers, which may be a source of wound infection. Wound cultures are used to confirm an infection but do not prevent one. Sterile technique, not clean technique, would eliminate additional sources of infection. Continual low-dosage antibiotic infusions would not be effective due to increased metabolism in burn clients.
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When assessing a burn victim's skin the nurse notices the entire right and left upper extremities are red, moist, weeping, and blistered. How should the nurse document the degree and total body surface area (TBSA) burned?
- A. First-degree burn on 9% TBSA
- B. Partial-thickness burn on 18% TBSA
- C. Partial-thickness burn on 27% TBSA
- D. Full-thickness burn on 36% TBSA
Correct Answer: B
Rationale: Partial-thickness burns damage the dermis and epidermis, often resulting in loss of epidermis and/or blistering. Each entire upper extremity is blistered. Approximately 18% of the TBSA has a partial-thickness burn (9% TBSA per each upper extremity). This is not a first-degree burn—In a first-degree burn the skin may appear red but intact, no weeping, and no blistering. With full-thickness burns there would be loss of tissue and a black or white charred/waxy appearance to the remaining tissues.
Which statement made to the nurse is the best evidence that the client understands the anticipated outcome of this procedure?
- A. I'm better night vision.
- B. I'll correctly identify colors.
- C. I'll see well without glasses.
- D. I'll use both eyes when reading.
Correct Answer: C
Rationale: LASIK corrects refractive errors, reducing the need for glasses.
The client receives treatment for uncomplicated lower-extremity cellulitis. The nurse notes improvement in the client's condition when which observation is noted on assessment?
- A. Decreased swelling in the lower extremity
- B. Strong dorsalis pedis pulses felt bilaterally
- C. Increased erythema in the lower extremity
- D. White blood cell (WBC) count 14,000/mm3
Correct Answer: A
Rationale: Cellulitis is an infection with diffuse inflammation occurring in the tissue just under the skin. Observing a decrease in swelling is evidence of improvement. Circulation is not involved with cellulitis, so pedal pulses are unaffected. Increased erythema indicates worsening. A WBC of 14,000/mm3 is elevated, indicating infection.
What is the best advice the nurse can offer the nursing assistant?
- A. Rinse your latex gloves with running tap water before putting them on.
- B. Apply a petroleum ointment to both hands before putting on latex gloves.
- C. Don't wear gloves, but wash your hands vigorously with alcohol after client contact.
- D. Wear two pairs of vinyl gloves when there's a potential for contact with body fluids.
Correct Answer: D
Rationale: Vinyl gloves avoid latex exposure while maintaining protection.
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply.
- A. Perform meticulous hand hygiene.
- B. Use sterile gloves for wound care.
- C. Wear gown and mask during procedures.
- D. Change central lines once a week.
- E. Administer antibiotics as prescribed.
Correct Answer: A,B,C,E
Rationale: Hand hygiene, sterile gloves, gown/mask, and antibiotics prevent infection in extensive burns. Weekly central line changes are not standard; daily assessment is preferred.