ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 Questions
Question 1 of 5
A client with a burn injury is in acute stress. The nurse knows that which of the following complications is prone to develop in this client?
Correct Answer: B
Rationale: The release of histamine as a consequence of the stress response increases gastric acidity. The client with a burn is prone to develop gastric ulcers. Anemia develops because of the heat destroying the erythrocytes. Release of histamine does not cause hyperthyroidism or cardiac arrest.
Question 2 of 5
Which zone consists of the area where the injury is most severe and deepest?
Correct Answer: A
Rationale: The zone of coagulation is at the center of the injury and is the area of injury that is most severe and the deepest. The zone of stasis is the area of intermediate burn injury. The zone of hyperemia is the area of least injury. Where the epidermis and dermis are only minimally damaged. There is no zone of necrosis.
Question 3 of 5
Which type of debridement occurs when nonliving tissue slough away from uninjured tissues?
Correct Answer: B
Rationale: Natural debridement is accomplished when nonliving tissue slough away from uninjured tissue. Mechanical debridement involves the use of surgical tools to separate and remove the eschar. Enzymatic debridement encompasses the use of topical enzymes to the burn wound. Surgical debridement uses the use of forceps and scissors during dressing changes or wound cleaning.
Question 4 of 5
Which is a disadvantage of surgical debridement?
Correct Answer: B
Rationale: A disadvantage of surgical debridement is bleeding. Scarring, loss of function, and contractures are not disadvantages of surgical debridement.
Question 5 of 5
What action should a nurse perform to help reduce the accumulation of debris within the burn wound?
Correct Answer: A
Rationale: The healthcare team should wear powder-free sterile gloves when handling the burn wound to reduce the accumulation of debris within the wound that may complicate the healing. After the wound has been cleansed, topical antimicrobial medications are used to minimize the risk of infection. The particles or fiber from cold comppresses, sponges, or sterilized gauze swaps may add to the accumulation of debris if used on a burn wound.