Davis Advantage Chapter 50

The nurse is explaining the difference between an escharotomy and a fasciotomy to the client's family. What information should the nurse share with the family? "A fasciotomy is a procedure performed to relieve pressure and only extends through the eschar and into the immediate subcutaneous fat. An escharotomy is an incision that extends through the subcutaneous fat and muscle fascia, allowing for expansion of the muscle compartment." "A fasciotomy is an incision that extends through the subcutaneous fat and muscle fascia, allowing for expansion of the muscle compartment. An escharotomy is a procedure performed to relieve pressure and only extends through the eschar and into the immediate subcutaneous fat." "A fasciotomy is the surgical removal of eschar tissue to promote healing and remove infection. An escharotomy is a procedure performed to relieve pressure and only extends through the eschar and into the immediate subcutaneous fat." "The terms fasciotomy and escharotomy are used interchangeably for a procedure that is used to remove eschar to promote healing and remove infection."

"A fasciotomy is an incision that extends through the subcutaneous fat and muscle fascia, allowing for expansion of the muscle compartment. An escharotomy is a procedure performed to relieve pressure and only extends through the eschar and into the immediate subcutaneous fat."

How would the nurse explain to the client the difference between a strain and a sprain? "A sprain is the tearing of a muscle, tendon, or ligament; a strain is the stretching of a muscle, tendon, or ligament." "A sprain is stretching of a muscle, tendon, or ligament; a strain is the tearing of a muscle, tendon, or ligament." "A sprain is the stretching or tearing of a muscle or tendon; a strain is the stretching or tearing of a ligament." "A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

"A sprain is the stretching or tearing of a ligament; a strain is the stretching or tearing of a muscle or tendon."

The nurse is explaining to the student nurse the difference between undermining and tunneling. How should the nurse explain the two terms? "Undermining is measuring a passageway under the skin surface and tunneling is the destruction of tissue extending under the wound edges." "Undermining is the measurement of the wound's length from head to toe and tunneling is the measurement of the wound's widest point perpendicular to the length." "Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface." "Undermining is the development of infection in the wound bed of the wound and tunneling is the development of necrotic tissue over the wound."

"Undermining is the destruction of tissue under the wound edges and tunneling is the development of a passageway under the skin's surface."

The nurse is caring for a client in the intensive care unit who is 36 hours post-deep partial-thickness burn to the left lower extremity. Which nursing interventions would be in place to decrease the development of compartment syndrome? Monitor pulses in both burned and unburned extremities every 8 hours. Assess pulses hourly in burned and unburned extremities. Monitor sodium and potassium levels every 4 hours. Maintain the head of the client's bed at 45 degrees.

Assess pulses hourly in burned and unburned extremities.

The nurse caring for the client with burns knows which factors may impact the severity of the burn injury? Select all that apply. Client's age Client's gender Physical location of the burn Client's past medical history Involvement of an inhalation injury with the burn

Client's age Physical location of the burn Client's past medical history Involvement of an inhalation injury with the burn

The nursing student is observing in the burn unit. The student would expect to see which infection control measures implemented in the burn unit? Select all that apply. Contact precautions for all client interactions Use of antibiotic-coated intravenous and central line catheters Use of betadine hand scrub by nursing staff before and after caring for clients Changing Foley catheters every 72 hours Use of disposable equipment such as blood pressure cuffs and stethoscopes

Contact precautions for all client interactions Use of antibiotic-coated intravenous and central line catheters Use of disposable equipment such as blood pressure cuffs and stethoscopes

The nurse is caring for a client with a femoral shaft fracture. Which types of fracture may the client have? Select all that apply. Transverse Greenstick Comminuted Compound Displaced

Greenstick Communicated

A client with a major burn injury is at great risk of burn shock. What factor causes this type of shock? Infection Massive fluid shift Loss of blood Organ dysfunction

Massive fluid shift

The nurse is caring for a client with a blunt trauma and tissue injury to the lower extremity. Which signs could develop in a client with compartment syndrome? Increased pain in the affected extremity upon ambulation Numbness in the toes of the affected extremity Passive pain at rest in the affected extremity Absence of pain in the affected extremity

Passive pain at rest in the affected extremity

The nurse caring for a burn client is monitoring the lab values of what two electrolytes most closely during the burn shock phase? Potassium and sodium Chloride and magnesium Calcium and potassium Sodium and chloride

Potassium and sodium

Compartment Syndrome Assessments

Pressure at surgical site numbness in operative extremity passive pain at rest

The nurse is caring for a client post-open reduction internal fixation surgery. Which complications should the nurse monitor for? Select all that apply. Respiratory distress Fat embolism syndrome Elevated blood urea nitrogen and creatinine Elevated serum potassium Hypovolemia

Respiratory distress Fat embolism syndrome Hypovolemia

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Additional Potential Complications

Respiratory distress Venous thromboemboli Hypovolemia Fat embolism syndrome

The nurse is caring for a client who was involved in a crush injury of the lower extremity and experiencing severe flank pain and the presence of dark, tea-colored urine. The nurse is aware of the potential for which serious complication? Pulmonary embolism Rhabdomyolysis Compartment syndrome Fat embolism

Rhabdomyolysis

The nurse is aware the client with a burn has a deep partial thickness burn when making which assessment observation? The burn affects only the epidermal layer of the skin. The burn affects the epidermis through to the superficial layers of the dermis. The burn affects the epidermis through to the lower layers of the dermis. The burn affects the epidermis, dermis, and portions of the subcutaneous tissue.

The burn affects the epidermis through to the lower layers of the dermis.

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Fasciotomy:

Treatment for compartment syndrome Urgent procedure Helps to pressure from internal edema

The nurse is caring for a client who has a large full-thickness burn and is going to the operating room to have a burn excision. The nurse notes on the surgical consent that an allograft is planned. The tissue for an allograft is from which source? The client's own skin The skin from a pig The skin from a cadaver The skin grown in the lab from a biopsy of the client's own skin

The skin from a cadaver

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Nursing Actions

begin preoperative teaching prepare client for fasciotomy assist with dressing removal

Identify the postoperative nursing processes for a client who has had an orthopedic surgical revision for a fracture (open reduction internal fixation - ORIF) and has developed compartment syndrome. Most common symptoms

pallor paralysis pain pulselessness pressure paresthesia