ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 66 Questions
Question 1 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.
Question 2 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 3 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 4 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 5 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.