Exam 1 Questions 66-100

Which of the following is a true statement regarding the purposes of skin grafts?

Correct response: Reduces scarring and contractures. Explanation: Purposes of a skin graft include the reduction of scarring and contractures, to decrease evaporative fluid loss, decrease the potential for infection, and speed recovery.

Which of the following clients with burns is more prone to infection and requires close monitoring by the nurse?

Correct response: A client with burns in the perineal area Explanation: The nurse should closely monitor for infection from organisms in the stool in a client with burns in the perineal area because the area is susceptible to bacterial colonization. Burns of the face, neck, or chest have the potential to impair ventilation, while those involving the hands, legs, abdominal area, or major joints may affect dexterity and mobility.

An emergency department nurse has just received a client with burn injuries brought in by ambulance. The paramedics have started a large-bore IV and covered the burn in cool towels. The burn is estimated as covering 24% of the client's body. How should the nurse best address the pathophysiologic changes resulting from major burns during the initial burn-shock period?

Correct response: Administer IV fluids Explanation: Pathophysiologic changes resulting from major burns during the initial burn-shock period include massive fluid losses. Addressing these losses is a major priority in the initial phase of treatment. Antibiotics and PRBCs are not normally given. Potassium chloride would exacerbate the client's hyperkalemia.

A client is brought to the ED by paramedics, who report that the client has partial-thickness burns on the chest and legs. The client has also suffered smoke inhalation. What is the priority in the care of a client who has been burned and suffered smoke inhalation?

Correct response: Airway management Explanation: Systemic threats from a burn are the greatest threat to life. The ABCs of all trauma care apply during the early post-burn period. While all options should be addressed, pain, fluid balance, and anxiety and fear do not take precedence over airway management.

The outer layer of the epidermis provides the most effective barrier to penetration of the skin by environmental factors. Which of the following is an example of penetration by an environmental factor?

Correct response: An insect bite Explanation: The stratum corneum, the outer layer of the epidermis, provides the most effective barrier to both epidermal water loss and penetration of environmental factors, such as chemicals, microbes, insect bites, and other trauma. Dehydration, sunburn, and excessive perspiration are not examples of penetration of an environmental factor.

Vitiligo is due to which of the following?

Correct response: Areas of non-functioning melanocytes.

Appropriate treatment of a subungual hemorrhage includes which of the following?

Correct response: Assisting the physician as the doctor drills a small hole into the nail to create a means for blood to escape, and thus relieve pressure.

Which type of graft utilizes the client's own skin for wound coverage?

Correct response: Autograft Explanation: An autograft uses the client's own skin, which is transplanted from one part of the body to another. A heterograft is obtained from animals, principally pigs. An allograft is human skin obtained from a cadaver. A slit graft is used when the area available as a donor site is limited, as in clients with extensive burns.

Rank these skin cancers, in order from mildest form, to most likely to metastisize and become deadly.

Correct response: Basal Cell Carcinoma, Squamous Cell Carcinoma, Malignant Melanoma

Which of the following is a disadvantage of surgical debridement?

Correct response: Bleeding Explanation: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.

Which of the following is a common complication of an electrical burn injury?

Correct response: Cardiac dysrhythmias Explanation: Cardiac dysrhythmias and central nervous system complications are common among victims of electrical burns; localized edema, absent bowel sounds, and loss of mobility are not.

"Clubbing" of the nails indicates what condition in your client?

Correct response: Chronic hypoxia.

You are documenting the wound dressing change you just did on a post-op patient who had surgery on their right lower leg. The drainage is a mixture of clear fluid with a bloody tinge, and covered about 25% of the old dressing. The correct way to document a narrative note would be which of the following?

Correct response: Dressing changed on right lower extremity operative site for small amount of serosanguineous drainage.

Within the practice of nursing at the burn unit, there are specific potential complications common to specific types of burns. Which burns can impair ventilation?

Correct response: Face, neck, chest Explanation: Burns of the face, neck, or chest have the potential to impair ventilation.

Chemical burns of the eye are immediately treated by:

Correct response: Flushing the lids, conjunctiva, and cornea with tap water or normal saline. Explanation: The immediate response is to always flush the affected eyelid and eye with normal saline or tap water to dilute the effectiveness of the agent that is causing the burn.

Skin grafts are necessary for which of the following burns?

Correct response: Full-thickness Explanation: 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.

Which type of skin graft is more comparable in appearance to normal skin?

Correct response: Full-thickness graft Explanation: Full-thickness grafts are more comparable in appearance to normal skin and can tolerate more stress once they become permanently attached to the burn wound. A slit graft (lace graft) is used when the area available as a donor site is limited, as in clients with extensive burns. In a split thickness graft, the epidermis and a thin layer of the dermis are harvested from the client's skin.

A client with a burn injury is in acute stress. Which of the following complications is prone to develop in this client?

Correct response: Gastric ulcers Explanation: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric (Curling's) ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.

Your client, who was injured in a motor vehicle crash 13 months ago, sustained complete cervical transection of the spinal cord, and has permanent paralysis from the neck down. During the rehabilitative stay in a skilled nursing facility, he suffered a Stage IV pressure ulcer to his coccyx. Skin grafting was done, and the coccyx has now healed, and there is no evidence of redness to the area upon visual inspection.. What is the correct way to document this pressure ulcer?

Correct response: Healed Stage IV Pressure Ulcer to Coccyx

What are the expected findings in the fluid remobilization phase (acute phase, diuresis) that the nurse should monitor for? Select all that apply.

Correct response: Hemodilution Increased urinary output Sodium deficit Explanation: Hemodilution (decreased hematocrit), increased urinary output, metabolic acidosis (not alkalosis), sodium deficit, and hypokalemia (not hypoglycemia) are typical fluid and electrolyte changes that occur in the acute phase (fluid remobilization phase, state of diuresis).

Which of the following neuroendocrine changes occur within the first 24 hours of a serious burn?

Correct response: Hyperglycemia Explanation: When the adrenal cortex is stimulated, it releases glucocorticoids , which cause hyperglycemia. Sodium retention leads to peripheral edema. There is a decreased urine output, initially.

Which of the following types of shock will a nurse observe in a client with extensive burns?

Correct response: Hypovolemic shock Explanation: Clients with extensive burns may exhibit hypovolemic shock due to the loss of blood or plasma. Clients with extensive burns are unlikely to display the symptoms of anaphylactic, neurogenic, or septic shock.

A triage nurse in the emergency department (ED) receives a phone call from a frantic father who saw his 4-year-old child tip a pot of boiling water onto her chest. The father has called an ambulance. What should the nurse in the ED receiving the call instruct the father to do?

Correct response: Immerse the child in a cool bath. Explanation: After the flames or heat source have been removed or extinguished, the burned area and adherent clothing are soaked with cool water briefly to cool the wound and halt the burning process. Cool water is the best first-aid measure. Ice and butter are contraindicated. Appropriate first aid necessitates touching the burn.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Correct response: Ineffective airway clearance related to edema of the respiratory passages Explanation: When caring for a client with upper torso burns, the nurse's primary goal is to maintain respiratory integrity. Therefore, Ineffective airway clearance related to edema of the respiratory passages should take the highest priority. Impaired physical mobility related to the disease process isn't appropriate because burns aren't a disease. Disturbed sleep pattern related to facility environment and Risk for infection related to breaks in the skin may be appropriate, but they don't command a higher priority than Ineffective airway clearance because they don't reflect immediately life-threatening problems.

Which of the following is the effect of protein catabolism in a client with severe burns?

Correct response: It compromises wound healing and immunocompetence. Explanation: Protein catabolism in a client with severe burns compromises wound healing and immunocompetence. Burns of the face, neck, or chest have the potential to impair ventilation, while burns involving the hands or major joints may affect dexterity and mobility. Release of aldosterone, not protein catabolism, causes sodium retention.

After getting a tattoo, your client complains of a thick, raised scar that is obscuring the cosmetic effect of the tattoo. Upon examination, the scar is non-tender, but the desired appearance has not been achieved. There is no drainage from the healed skin. What is the name of this hypertrophic scarring?

Correct response: Keloid.

A client has partial-thickness burns on both lower extremities and portions of the trunk. Which IV fluid does the nurse plan to administer first?

Correct response: Lactated Ringer's solution Explanation: Lactated Ringer's solution replaces lost sodium and corrects metabolic acidosis, both of which commonly occur following a burn. Albumin is used as adjunct therapy, not as primary fluid replacement. D5W isn't given to burn clients during the first 24 hours because it can cause pseudodiabetes. The client is hyperkalemic as a result of the potassium shift from the intracellular space to the plasma, so giving potassium would be detrimental.

Your client is new to Northern CA and was hiking in the woods yesterday near their home. Today, they have developed inflammation, edema, and vesicle formation on their lower extremities. They state they were wearing shorts with low-cut socks, and they cut through the plants along the mountain trails as they explored nature. What condition is their skin exhibiting?

Correct response: Plant-Based Contact Dermatitis.

A client who was burned in a workplace accident has completed the acute phase of treatment and the plan of care has been altered to prioritize rehabilitation. What nursing action should be prioritized during this phase of treatment?

Correct response: Providing education to the client and family Explanation: Client and family education is a priority during rehabilitation. There should be no fluid and electrolyte imbalances in the rehabilitation phase. The presence of impaired thermoregulation or infection would suggest that the client is still in the acute phase of burn recovery.

Which type of burn is similar to a sunburn?

Correct response: Superficial partial-thickness Explanation: A superficial partial-thickness burn is similar to a sunburn. Deep partial thickness burns may need debridement and may scar. Full-thickness burns destroy all layers of the skin and consequently are painless. Electrical burns are a type of burn but not a category of burn thickness.

Your client is a 5 year old boy who was taken to a local Emergency Department after being bit by a feral cat in the right facial cheek. The elderly ER physician sutured the cat bite closed, but within 24 hours it became grossly infected, which necessitated another Emergency Department visit and the removal of the sutures, along with hospitalization and a surgical wound exploration and debridement in the Operating Room due to the extensive infection. The wound must now be left open to begin the process of healing. By which process will this wound heal?

Correct response: Tertiary Intention

A nurse is required to monitor the effectiveness of fluid resuscitation in a client who is being treated for burns. Which of the following assessments would indicate the success of the fluid resuscitation?

Correct response: The client's urinary output is 0.5 mL/kg/hour. Explanation: Successful fluid resuscitation is gauged by a urinary output of 0.5 mL/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.

A client receiving emergency treatment for severe burns has just been assessed to establish the burn depth. Why is a nurse asked to reassess the burn depth after 72 hours?

Correct response: The early appearance of the burn injury may change. Explanation: The nurse is required to reassess and revise the estimate of burn depth because the early appearance of the burn injury may change. Assessing the burn depth helps determine the potential of the damaged tissue to survive. It does not establish the percentage of the TBSA that is burned or minimize the risk of infections. It also does not help determine whether the client's condition is likely to deteriorate after 72 hours.

A client with deep partial-thickness and full-thickness burns on the arms receives autografts. Two days later, the nurse finds the client doing arm exercises. The nurse provides additional client teaching because these exercises may:

Correct response: dislodge the autografts. Explanation: Because exercising the autograft sites may dislodge the grafted tissue, the nurse should advise the client to keep the grafted extremity in a neutral position. Exercise doesn't cause increased edema, increased scarring, or decreased circulation.

A nurse is developing a care plan for a client recovering from a serious thermal burn. After maintaining respirations, the nurse knows that the most important immediate goal of therapy is:

Correct response: maintaining the client's fluid, electrolyte, and acid-base balance. Explanation: After maintaining respirations, the most important immediate goal of therapy for a client with a serious thermal burn is to maintain fluid, electrolyte, and acid-base balance to avoid potentially life-threatening complications, such as shock, disseminated intravascular coagulation, respiratory failure, cardiac failure, and acute tubular necrosis. Planning for the client's rehabilitation and discharge, providing emotional support, and preserving full range of motion in all affected joints are important aspects of care but don't take precedence over maintaining the client's fluid, electrolyte, and acid-base balance.