Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be:

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Dermis is partially damaged. Superficial partial-thickness burns involve damage to the epidermis and superficial layers of the dermis. This type of burn is characterized by redness, blistering, and pain. By selecting this option, the nurse accurately informs Sergio's wife that the burn has affected the outermost layer of skin and partially penetrated the dermis. Option A) Structures beneath the skin are damaged is incorrect because superficial partial-thickness burns do not typically extend beyond the dermis. Option C) Epidermis and dermis are both damaged is incorrect as it describes a full-thickness burn, not a partial-thickness burn like Sergio's. Option D) Epidermis is damaged is also incorrect as a superficial partial-thickness burn involves damage to both the epidermis and dermis. Educationally, understanding the depth and severity of burns is crucial for providing appropriate care and educating patients and their families. By accurately identifying the type of burn, healthcare providers can develop effective treatment plans and prevent complications. It is essential for nurses to be knowledgeable about burn classifications to ensure optimal patient outcomes.

Correct Answer: C

Rationale: In the event of an adverse hemolytic reaction during a blood transfusion, the correct nursing intervention should focus on stopping the infusion, calling the physician, and assessing the client (Option C). This is the correct answer because a hemolytic reaction can be life-threatening and requires immediate action to prevent further harm to the patient. Option A is incorrect because simply slowing the infusion may not be sufficient to address the serious nature of a hemolytic reaction. Calling the physician and assessing the patient are important steps, but stopping the infusion is crucial. Option B is incorrect because sending the remaining blood to the laboratory is not a priority when the client's safety is at risk. Stopping the infusion and assessing the client should take precedence. Option D is incorrect because in the case of a hemolytic reaction, just slowing the infusion and keeping a patent IV line open for medication administration is not enough. The priority is to stop the infusion and address the adverse reaction promptly. From an educational perspective, understanding the importance of immediate action in the face of a potentially life-threatening situation like a hemolytic reaction during a blood transfusion is crucial for nurses. This scenario emphasizes the significance of rapid assessment, critical thinking, and prioritization in providing safe and effective patient care in clinical practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Potassium chloride. After surgery, Leda is experiencing symptoms of hypocalcemia, which is characterized by peripheral numbness, tingling, and muscle twitching/spasms. Potassium chloride is administered to treat hypocalcemia because potassium plays a vital role in maintaining proper muscle and nerve function. By administering potassium chloride, the levels of potassium in the body can be restored, helping to alleviate Leda's symptoms. The other options are incorrect for this situation: A) Magnesium sulfate is used to treat magnesium deficiency, not hypocalcemia. B) Calcium gluconate is used to treat calcium deficiencies, but in this case, the symptoms are indicative of low potassium levels, not calcium. C) Potassium iodide is used to treat iodine deficiency and is not relevant to the symptoms described. This educational context highlights the importance of understanding electrolyte imbalances post-surgery and the significance of selecting the appropriate treatment based on the specific electrolyte affected. Nurses must be able to recognize symptoms of electrolyte imbalances and understand the pharmacological interventions required to address them effectively to ensure patient safety and recovery.

Correct Answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.

Correct Answer: C

Rationale: In the context of pharmacology and wound healing, understanding the causes of hypertrophic burn scars is crucial. The correct answer is C) wound ischemia. This is because hypertrophic scars result from an overgrowth of collagen during the healing process due to inadequate blood supply to the wound site, leading to ischemia. This results in excessive collagen production and fibrosis, characteristic of hypertrophic scars. Option A) exaggerated contraction is incorrect because it refers to keloid scars, which result from excessive collagen synthesis rather than wound ischemia. Option B) random layering of collagen is incorrect as it does not specifically address the vascular component of hypertrophic scarring. Option D) delayed epithelialization is incorrect as it pertains to a different aspect of wound healing and does not directly contribute to hypertrophic scarring. Educationally, this question underscores the importance of understanding the pathophysiology of wound healing and the factors contributing to different types of scars. Pharmacological interventions in wound care aim to optimize healing processes and prevent complications such as hypertrophic scarring, making this knowledge essential for healthcare professionals managing patients with burns and wounds.