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The nurse is providing education to the client with multiple burns and lists the options for skin grafting and application techniques. Which is the primary benefit for using an autograft slit graft versus other types of grafts?
- A. Less scarring
- B. Less discomfort
- C. Speeds healing
- D. Rejection is unlikely.
Correct Answer: D
Rationale: In an autograft slit graft, the skin is harvested from the client's buttocks or thighs. Rejection is less likely with this type of graft because the donor and recipient are the same. There will be scarring at both the donor and recipient sites, and added discomfort is associated from the donor site. Because the slit graft is expanded through a meshing device, the scarring will appear as a mesh. Healing is delayed due to need for two wounds.
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An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
- A. 9%
- B. 18%
- C. 27%
- D. 36%
Correct Answer: D
Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. None of the other answer choices correctly applies the Rule of nines.
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.
What action should a nurse perform to help reduce the accumulation of debris within the burn wound?
- A. Use powder-free sterile gloves.
- B. Use topical antimicrobial medications.
- C. Use cold comppresses or sponges.
- D. Use sterilized gauze swaps.
Correct Answer: A
Rationale: The healthcare team should wear powder-free sterile gloves when handling the burn wound to reduce the accumulation of debris within the wound that may complicate the healing. After the wound has been cleansed, topical antimicrobial medications are used to minimize the risk of infection. The particles or fiber from cold comppresses, sponges, or sterilized gauze swaps may add to the accumulation of debris if used on a burn wound.
Which type of debridement occurs when nonliving tissue slough away from uninjured tissues?
- A. Mechanical
- B. Natural
- C. Enzymatic
- D. Surgical
Correct Answer: B
Rationale: Natural debridement is accomplished when nonliving tissue slough away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
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.