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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.
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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.
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.
A nurse is caring for a client with facial burns who is prescribed the open method treatment. What nursing intervention should the nurse perform?
- A. Administer a cold sponge bath to the client.
- B. Keep the client's room cool and airy.
- C. Place a bed cradle or sheets over the client.
- D. Place the client on a moist linen sheet.
Correct Answer: C
Rationale: The skin of the client with burn is sensitive to drafts and temperature changes; therefore, a bed cradle or sheets should be placed over the client. The room should be kept warm and humidified, not cool and airy. The client should be placed in isolation in a bed with sterile, dry linen. Whirlpool baths are prescribed to loosen the crust, or eschar, which forms over the wound. Sponge baths are not advisable because particles from the sponge may cause accumulation of debris within the burn wound. Moist linen sheets are not placed on clients anymore due to their cooling effect, and they can lead the client to work hard to maintain proper body temperature.
Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply.
- A. Lessen potential for infection
- B. Maximizes fluid loss
- C. Promotes granulation of tissue
- D. Covers the unstractiveness of the wound
- E. Sows regeneration of tissue
- F. Diminishes pain
Correct Answer: A,F
Rationale: Skin substitutes provide a temporary covering of the burn area and lessen the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.
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.