Nokea
The nurse is preparing the patient for mechanical debridement and informs the patient that this will involve which of the following procedures?
- A. A spontaneous separation of dead tissue from the viable tissue
- B. Removal of eschar until the point of pain and bleeding occurs
- C. Shaving of burned skin layers until bleeding, viable tissue is revealed
- D. Early closure of the wound
Correct Answer: B
Rationale: Mechanical debridement involves manually removing eschar with tools like scissors or forceps until pain and bleeding indicate viable tissue. Spontaneous separation is natural debridement, shaving is surgical, and early closure is not debridement.
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A nurse who is taking care of a patient with burns is asked by a family member why the patient is losing so much weight. The patient is currently in the intermediate phase of recovery. What would be the nurses most appropriate response to the family member?
- A. Hes on a calorie-restricted diet in order to divert energy to wound healing.
- B. His body has consumed his fat deposits for fuel because his calorie intake is lower than normal.
- C. He actually hasnt lost weight. Instead, theres been a change in the distribution of his body fat.
- D. He lost many fluids while he was being treated in the emergency phase of burn care.
Correct Answer: B
Rationale: Hypermetabolism in the acute phase causes significant weight loss as the body catabolizes fat reserves, despite increased nutritional support. Calorie restriction is not used, fluid loss is earlier, and fat distribution changes are not typical.
A patient who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?
- A. Monitoring fluid and electrolyte imbalances
- B. Providing education to the patient and family
- C. Treating infection
- D. Promoting thermoregulation
Correct Answer: B
Rationale: Education for the patient and family is a priority in the rehabilitation phase to support self-care and adjustment. Fluid imbalances, infection, and thermoregulation are addressed in the acute phase.
A patient has experienced an electrical burn and has developed thick eschar over the burn site. Which of the following topical antibacterial agents will the nurse expect the physician to order for the wound?
- A. Silver sulfadiazine 1% (Silvadene) water-soluble cream
- B. Mafenide acetate 10% (Sulfamylon) hydrophilic-based cream
- C. Silver nitrate 0.5% aqueous solution
- D. Acticoat
Correct Answer: B
Rationale: Mafenide acetate penetrates thick eschar, making it ideal for electrical burns with deep tissue involvement. Silver sulfadiazine and silver nitrate do not penetrate eschar effectively, and Acticoat is a dressing, not a topical agent.
A nurse is teaching a patient with a partial-thickness wound how to wear his elastic pressure garment. How would the nurse instruct the patient to wear this garment?
- A. 4 to 6 hours a day for 6 months
- B. During waking hours for 2 to 3 months after the injury
- C. Continuously
- D. At night while sleeping for a year after the injury
Correct Answer: C
Rationale: Elastic pressure garments should be worn continuously (23 hours/day) to minimize scarring and contractures, typically for months until scars mature.
A patient has experienced burns to his upper thighs and knees. Following the application of new wound dressings, the nurse should perform what nursing action?
- A. Instruct the patient to keep the wound site in a dependent position.
- B. Administer PRN analgesia as ordered.
- C. Assess the patients peripheral pulses distal to the dressing.
- D. Assist with passive range of motion exercises to set the new dressing.
Correct Answer: C
Rationale: Checking peripheral pulses ensures dressings are not too tight, preventing circulatory compromise. Dependent positioning is avoided, analgesia is given before dressing changes, and ROM exercises are not typically post-dressing.