Rehabilitation is the final phase of the burn care. Which of the following are the goals during this phase? Select all that apply
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Solution
Provide emotional support., C. Promote wound healing and proper nutrition., E. Help the client in gaining optimal physical functioning.,
Options B and D belongs to the main goal during the resuscitative phase.
A client is prescribed by the physician to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure?
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Solution
“It is performed at the bedside and without anesthesia”.
Escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury.
Option A refers to skin autograft.
Option B Escharotomy involves making a lengthwise incision through the burn eschar to relieve vasoconstriction.
Option D refers to enzymatic debridement.
A client is being discharged today after undergoing autografting. What would the nurse include in the discharge instructions?
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Solution
Avoid smoking.
Avoiding smoking since it can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases.
Option A: The aPTT determines the effects of heparin therapy.
Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank?
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Solution
Homograft.
Option A: Autograft: Skin taken from a remote unburned area of client’s own body.
Options C and D: Xenograft or Heterograft: graft of tissue taken from a donor of one species and grafted into a recipient of another species.
A client sustained burns on the back. These areas appear dry, blotchy cherry red, blistering, doesn’t blanch, no capillary refill and reduced or absent sensation. This type of burn depth is classified as?
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Solution
Deep partial-thickness burn.
Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn’t blanch, no capillary refill and reduced or absent sensation. Generally, heals in 3-6 weeks, but scar formation results and skin grafting may be required.
Option A: Superficial partial-thickness: red, glistening, pain, absence of blisters and brisk capillary refill. Not life-threatening and normally heal within a week, without scarring.
Option B: pale pink or mottled appearance with associated swelling and small blisters. With a wet, shiny, and weeping surface is also a characteristic. Brisk capillary refill.
Option D: Full-thickness: dry, white or black, no blisters, absent capillary refill and absent sensation. Requires surgical repair and grafting.
Nurse Kelsey is a nurse manager assigned in the burn unit. Which client is best to assigned to an RN who has floated from the surgery unit?
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Solution
A client with infected partial-thickness back and chest burns who has a dressing scheduled.
Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit.
Options B, C, and D: Admission assessment, splinting and discharge teaching require expertise in caring for burn patients.
A client is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders?
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Solution
Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour.
The client’s urine output indicates inadequate fluid resuscitation. Hence the physician would order an increase amount of lactated Ringer’s solution administered hourly.
Option B: Blood transfusion is not used for fluid resuscitation therapy unless there is an indication of a low hemoglobin level.
Option C: Diuretic works by removing circulating volume, thereby further compromising the inadequate tissue perfusion.
Option D: Dextrose in water will only maintain fluid balance since it is an isotonic solution, therefore will not be helpful in this situation.
The nurse manager is observing a new nursing graduate caring for a burned client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?
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Solution
Wearing gloves and a gown only when giving direct care to the client.
Option A: Thorough handwashing is performed before and after each contact with the burn-injured client.
Option B: Protective garbs such as mask, gloves, cap, shoe covers, gowns, and a plastic apron need to be worn when having a direct contact with the client.
Option C: Sterile sheets and linen are used due to the high risk for infection.
The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury?
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Solution
Increased hematocrit levels.
The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours following the injury. During this phase, there is an elevation of the hematocrit levels due to hemoconcentration from the large fluid shifts
Option A: Blood pressure is decreased due to the shifting of fluids.
Option C: Pulse rate is higher than normal.
Option D: Initially, blood is shunted away from the kidneys, resulting in low urine output.
Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following client requires the most immediate care?
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Solution
A 40-year-old with partial thickness leg burns which has a temperature of 101.9°F and a blood pressure of 89/48 mm Hg.
The client’s vital signs indicate that life-threatening complications of sepsis may be developing.