Nokea
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.
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The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
- A. Tissue hypoxia
- B. Infection
- C. Renal failure
- D. Hypovolonia
Correct Answer: D
Rationale: After a burn, fluid from the body moves toward the barmed area, which leads to intravascular fluid deficit. Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the issues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that was destroyed during the burn can result in acute renal failure. Destruction of the skin barrier result in colonization of bacteria and can lead to life-threatening infection in days following the burn.
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.
Which is a disadvantage of surgical debridement?
- A. Scarring
- B. Bleeding
- C. Loss of function
- D. Contractures
Correct Answer: B
Rationale: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.
A client is brought to the ED with burns exceeding 20% of total body surface area. Which is the primary nursing intervention in the care of this client?
- A. Prevent infection
- B. Fluid resuscitation
- C. Endotracheal tube placement
- D. Strict intake and output
Correct Answer: B
Rationale: Fluid resuscitation requirements are paramount in the management of clients having burns that exceed 20% of TBSA. Fluid resuscitation with crystaloid and colloid solutions is calculated from the time the burn injury occurred to restore the intravascular volume and prevent hypovolemic shock and renal failure. Infection prevention is a care consideration with all burns. Endotracheal tube placement may be necessary if respiratory factors indicate the need. Intake and output records are maintained to determine the success of fluid resuscitation efforts.