ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 : Caring for Clients With Burns Questions
Question 1 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.
Question 2 of 5
A nurse is monitoring the effectiveness of fluid resuscitation in a client who is being treated for burns. What assessment would indicate the success of the fluid resuscitation?
Correct Answer: B
Rationale: Successful fluid resuscitation is gauged by a urinary output of 0.5 to 1 ml/kg/hour via an indwelling catheter. Fluid resuscitation does not directly affect the client's heart rate, breathing, or mental status.
Question 3 of 5
The nurse is teaching a client who underwent a skin graft for a burn injury about the use of pressure garments. What instruction(s) should the nurse include in the teaching? Select all that apply.
Correct Answer: B,E
Rationale: When using a pressure garment, the nurse should instruct the client to wear the garment for at least 23 hours a day, not 12 hours a day. The client should contact the primary provider if the garment does not seem to fit. The nurse should instruct the client to hand wash, not machine wash, the pressure garment daily with a mild detergent. The garment should not be wring dry. Instead, the client should squeeze and roll the garment in a towel to remove as much moisture as possible. The client should also massage any moisturizers, lotions, creams, and petroleum-based ointments completely into the skin before donning the garment.
Question 4 of 5
What is a benefit(s) that supports the use of a closed method wound care in the management of a client with burns? Select all that apply.
Correct Answer: C,E
Rationale: The closed method is the preferred method of wound management for most burn victims. It creates a microbial barrier and applies direct pressure to the wound, which reduces pain during position changes. Closed wound management provides a moist environment while reducing heat loss and evaporation, which facilitates faster healing. Frequent dressing changes may be required if the wound is infected or when there is significant exudate accumulation.
Question 5 of 5
Skin substitutes are often used after the wound is debrided and cleaned. What is the purpose(s) for the use of a skin substitute? Select all that apply.
Correct Answer: A,F
Rationale: Skin substitutes provide a temporary covering of the burn area and lessen the potential for infection. The covering decreases pain associated with contact and exposure to the air. The covering decreases fluid loss through evaporation and discourages granulation tissue, which contains fibroblasts causing scars. The skin substitute promotes tissue generation and healing.