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 nurse is caring for a client with facial burns who is prescribed the open method treatment. What nursing intervention should the nurse perform?
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.
Question 2 of 5
Skin grafts are necessary for what type of burn?
Correct Answer: C
Rationale: 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.
Question 3 of 5
What skin substitute is a nylon-silcone membrane coated with a protein derived from pig tissue?
Correct Answer: D
Rationale: Biobrane is a nylon-silcone membrane coated with a protein derived from pig tissue. Mederma is a topical gel that can reduce scarring. Integra consists of a two-layer membrane- one is a synthetic epidermal layer, and the other contains cross-linked collagen fibers that mimic the dermal layer of skin. TransCyte is created by culturing human fibroblasts from the dermis with a biosynthetic semipermeable membrane attached to nylon mesh.
Question 4 of 5
Which type of skin graft is more comparable in appearance to normal skin?
Correct Answer: B
Rationale: 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.
Question 5 of 5
The nurse receives a client following a serious thermal burn. Which complication will the nurse take action to prevent first?
Correct Answer: D
Rationale: After a burn, fluid from the body moves toward the barmed area, which leads to intravascular fluid deficit.
Steps must be taken to prevent irreversible hypovolemic shock in the initial stages of treatment. The inflammatory processes that affect the issues cause additional injury, which contributes to tissue hypoxia. Myoglobin and hemoglobin that was destroyed during the burn can result in acute renal failure. Destruction of the skin barrier result in colonization of bacteria and can lead to life-threatening infection in days following the burn.