ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 : Caring for Clients With Burns Questions
Question 1 of 5
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?
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.
Question 2 of 5
Which of the following would indicate the need to increase fluids beyond what is recommended for fluid resuscitation?
Correct Answer: A
Rationale: Myoglobin from muscle tissue destruction is transported to the kidneys for excretion and can cause tubular necrosis and acute renal failure. Increase in fluid intake until urine output clears is recommended in serious burns. An increase in ADH release is expected as the body tries to prevent hypovolemic shock. Elevation in glucose levels occurs when the adrenal cortex is stimulated. Sodium levels rise in response to aldosterone levels, which directly leads to peripheral edema.
Question 3 of 5
A client presents with a full-thickness burn to the anterior chest. The leathery skin is tight, making breathing difficult. The nurse anticipates which treatment management technique in the care of this client?
Correct Answer: C
Rationale: In areas of full-thickness burns, eschar constricts the area and can impair circulation or expansion of the anterior chest wall. An escharostomy is performed to release the burn tissue on the anterior chest, freeing the chest for expansion with inspiration. Endotracheal tube insertion, tracheostomy, and ventilation do not correct the tightening of the chest and poor expansion issue.
Question 4 of 5
Following a burn to a large area of the body, the client receives an Oasis porcine graft. Which statement by the client indicates an understanding of the use of this grafting material?
Correct Answer: B
Rationale: A xenograft, such as Oasis, is a temporary cover that will be rejected in days to weeks and will need to be replaced or removed at that time. A porcine graft originates from a pig. Autologous skin cell isolation grafting requires a 5 cm x 5 sample of skin that is separated and sprayed on the wound. Cadaver skin and or stem cells from umbilical cord blood are grafting material that is harvested from another human.
Question 5 of 5
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?
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.