ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 : Caring for Clients With Burns Questions
Question 1 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 2 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 3 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.
Question 4 of 5
A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary?
Correct Answer: A
Rationale: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.
Question 5 of 5
An emergency department nurse is evaluating a client with partial-thickness burns to the entire surfaces of both legs. Based on the rule of nines, what is the percentage of the body burned?
Correct Answer: D
Rationale: According to the rule of nines, the anterior portion of the lower extremity is 9% and the posterior portion of the lower extremity is 9%. Each lower extremity is therefore equal to 18%. Both lower extremities that have sustained burns to entire surfaces will equal to 36% of total surface area. None of the other answer choices correctly applies the Rule of nines.