Nokea
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.
- A. Wear the garment at least 12 hours each day.
- B. Contact the primary provider if the garment does not seem to fit properly.
- C. Machine wash the pressure garment daily with a mild detergent.
- D. Roll the garment and wring tightly to ensure garment is as dry as possible after washing.
- E. Massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
Correct Answer: B,E
Rationale: When using a pressure garment, the nurse should instruct the client to wear the garment for at least 23 hours a day, not 12 hours a day. The client should contact the primary provider if the garment does not seem to fit. The nurse should instruct the client to hand wash, not machine wash, the pressure garment daily with a mild detergent. The garment should not be wring dry. Instead, the client should squeeze and roll the garment in a towel to remove as much moisture as possible. The client should also massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
You may also like to solve these questions
Skin grafts are necessary for what type of burn?
- A. Superficial
- B. Superficial partial thickness
- C. Full-thickness
- D. First degree
Correct Answer: C
Rationale: Skin grafts are necessary for a full-thickness burn because the skin cells no longer are alive to regenerate. Superficial (first degree), superficial partial-thickness burns do not usually need skin grafting.
An explosion of a fuel tanker has resulted in melting of clothing on the driver and extensive full-body burns. The client is brought into the emergency department alert, denying pain, and joking with the staff. Which is the best interpretation of this behavior?
- A. The client is in hypovolemic shock.
- B. The client has experienced extensive full-thickness burns.
- C. The paramedita administered high doses of opioids during transport.
- D. The client has experienced partial-thickness burns.
Correct Answer: B
Rationale: In full-thickness burns, nerves are damaged and consequently painless. Behavior change is not a significant symptom of hypovolemic shock. Opoids are used in the management of pain associated with partial-thickness burns but not significant in the behavior exhibited. Partial-thickness burns are associated with increased pain to the area of involvement.
A client is brought to the emergency department after sustaining a serious burn. The nurse understands that the focused management of which burn zone is of greatest concern?
- A. Zone in burn center
- B. Zone of coagulation
- C. Zone of hyperemia
- D. Zone of stasis
Correct Answer: D
Rationale: The zone of stasis lies outside the burn center and zone of coagulation. This is where the blood vessels are damaged, but tissue has the potential to survive with proper management. The center zone or zone of coagulation is the deepest area of injury and is considered the zone of irreversible damage, placing the focus on saving the surrounding tissues. The zone of hyperemia is the area of least injury.
What is a benefit(s) that supports the use of a closed method wound care in the management of a client with burns? Select all that apply.
- A. Provides a drier environment
- B. Promotes heat loss
- C. Creates microbial barrier
- D. Prevents exudate accumulation
- E. Reduces pain during position changes
- F. Promotes slower healing
Correct Answer: C,E
Rationale: The closed method is the preferred method of wound management for most burn victims. It creates a microbial barrier and applies direct pressure to the wound, which reduces pain during position changes. Closed wound management provides a moist environment while reducing heat loss and evaporation, which facilitates faster healing. Frequent dressing changes may be required if the wound is infected or when there is significant exudate accumulation.
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.