FULL-TEXT: Burns & Burn Injury (100 Questions)

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Burns NCLEX Question and Burn Injury Nursing Management Quiz #2 (20 Items)

NURSESLABS-BURNINJURY-02-001

The RN has assigned a client who has an open burn wound to the LPN. Which instruction is most important for the RN to provide the LPN?

  • A. Administer the prescribed tetanus toxoid vaccine.
  • B. Assess wounds for signs of infection.
  • C. Encourage the client to cough and breathe deeply.
  • D. Wash hands on entering the client’s room.

Correct Answer: D. Wash hands on entering the client’s room.

Infection can occur when microorganisms from another person or the environment are transferred to the client. Handwashing with soap and water is the best way to get rid of germs in most situations. Emphasize and model good handwashing techniques for all individuals coming in contact with the patient.

  • Option A: Tissue destruction and altered defense mechanisms increase the risk of developing tetanus or gas gangrene, especially in deep burns such as those caused by electricity.
  • Option B: Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention.
  • Option C: Although all the interventions listed can help reduce the risk of infection, hand washing is the most effective technique for preventing infection transmission. Airway obstruction and/or respiratory distress can occur very quickly or may be delayed, e.g., up to 48 hr after a burn.

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NURSESLABS-BURNINJURY-02-002

Three days after a burn injury, the client develops a temperature of 100° F, a white blood cell count of 15,000/mm3, and a white, foul-smelling discharge from the wound. The nurse recognizes that the client is most likely exhibiting symptoms of which condition?

  • A. Acute phase of the injury
  • B. Autodigestion of collagen
  • C. Granulation of burned tissue
  • D. Wound infection

Correct Answer: D. Wound infection 

Color change, purulent, foul-smelling drainage, increased white blood cell count, and fever could all indicate infection. Indicators of sepsis (often occurs with full-thickness burn) requiring prompt evaluation and intervention. Changes in sensorium, bowel habits, and the respiratory rate usually precede fever and alteration of laboratory studies.

  • Option A: These symptoms will not be seen in the acute phase of the injury. Assess and document size, color, depth of wound, noting necrotic tissue and condition of the surrounding skin.
  • Option B: Autodigestion of collagen will not increase the body temperature or cause foul-smelling wound discharge. Monitor vital signs for fever, increased respiratory rate and depth in association with changes in sensorium, presence of diarrhea, decreased platelet count, and hyperglycemia with glycosuria.
  • Option C: Granulation of tissue will not increase the body temperature or cause foul-smelling wound discharge. Examine wounds daily, note and document changes in appearance, odor, or quantity of drainage.

NURSESLABS-BURNINJURY-02-003

Twelve hours after the client was initially burned, bowel sounds are absent in all four abdominal quadrants. Which is the nurse’s best action?

  • A. Administers a laxative
  • B. Documents the finding
  • C. Increases the IV flow rate
  • D. Repositions the client onto the right side

Correct Answer: B. Documents the finding

Decreased or absent peristalsis is an expected response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. No currently accepted intervention changes this response. It is not the highest priority of care at this time.

  • Option A: Do not give the patient laxative. The emergent phase starts with the onset of burn injury and lasts until the completion of fluid resuscitation or a period of about the first 24 hours. During the emergent phase, the priority of patient care involves maintaining an adequate airway and treating the patient for burn shock.
  • Option C: Increased capillary permeability, protein shifts, inflammatory process, and evaporative losses greatly affect circulating volume and urinary output, especially during initial 24–72 hr after burn injury. Fluid replacement formulas partly depend on admission weight and subsequent changes.
  • Option D: Maintain proper body alignment with supports or splints, especially for burns over joints. This promotes functional positioning of extremities and prevents contractures, which are more likely over joints.

NURSESLABS-BURNINJURY-02-004

What intervention will the nurse implement to reduce a client’s pain after a burn injury?

  • A. Administering morphine 4 mg intravenously.
  • B. Administering hydromorphone (Dilaudid) 4 mg intramuscularly.
  • C. Applying ice to the burned area
  • D. Avoiding tactile stimulation

Correct Answer: A. Administering morphine 4 mg intravenously.

Drug therapy for pain management requires opioid and nonopioid analgesics. The burned patient may require around-the-clock medication and dose titration. IV method is often used initially to maximize drug effect.

  • Option B: The IV route is used because of problems with absorption from the muscle and stomach. Concerns of patient addiction or doubts regarding the degree of pain experienced are not valid during the emergent/acute phase of care, but narcotics should be decreased as soon as feasible and alternative methods for pain relief initiated.
  • Option C: For the client to avoid shivering, the room must be kept warm and heat should be applied. Maintain comfortable environmental temperature, provide heat lamps, heat-retaining body coverings. Temperature regulation may be lost with major burns. External heat sources may be necessary to prevent chilling.
  • Option D: Tactile stimulation can be used for pain management. Provide basic comfort measures: massage of uninjured areas, frequent position changes. This promotes relaxation and reduces muscle tension and general fatigue.

NURSESLABS-BURNINJURY-02-005

What statement indicates the client needs further education regarding skin grafting (allografting)?

  • A. “Because the graft is my own skin, there is no chance it won’t ‘take.'”
  • B. “For the first few days after surgery, the donor sites will be painful.”
  • C. “I will have some scarring in the area when the skin is removed for grafting.”
  • D. “I am still at risk for infection after the procedure.”

Correct Answer: A. “Because the graft is my own skin, there is no chance it won’t ‘take.'”

Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Graft survival depends on the diffusion of nutrients and oxygen from the wound bed known as imbibition. Inosculation then follows when the blood vessels of the graft and from the wound bed grow together to make end-to-end contact. Lastly, neovascularization occurs when new blood vessels grow from the wound bed into the graft.

  • Option B: The donor sites will be painful after the surgery. Silicone gel sheets, along with pressure dressings, have shown a dramatic decrease in pain, pruritus, and scar thickness six months after burn injury.
  • Option C: There can be scarring in the area where the skin is removed for grafting. Burn scars are a common occurrence after skin grafting and can cause anxiety, depression, pain, itching, altered pigmentation, temperature intolerance, and decreased range of motion secondary to scar contracture. Scar formation is propagated by deficiencies in the biosynthetic and tissue degradation pathway during wound healing.
  • Option D: The client is still at risk for infection. Early failure of graft survival is attributable to seroma and hematoma formation, which lifts the graft off the wound bed, preventing imbibition. Other factors that lead to graft failure include shearing forces, edematous tissue, and infected tissue. 

NURSESLABS-BURNINJURY-02-006

When providing care for a client with an acute burn injury, which nursing intervention is most important to prevent infection by auto contamination?

  • A. Avoiding sharing equipment such as blood pressure cuffs between clients.
  • B. Changing gloves between wound care on different parts of the client’s body.
  • C. Using the closed method of burn wound management.
  • D. Using proper and consistent handwashing.

Correct Answer: B. Changing gloves between wound care on different parts of the client’s body.

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.

  • Option A: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent auto contamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
  • Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
  • Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.

NURSESLABS-BURNINJURY-02-007

Which assessment finding assists the nurse in confirming inhalation injury?

  • A. Brassy cough
  • B. Decreased blood pressure
  • C. Nausea
  • D. Headache

Correct Answer: A. Brassy cough

Brassy cough and wheezing are some signs seen with inhalation injury. Damage to airway tissue causes increased mucus production, edema, denudation of epithelium, and mucosal ulceration and hemorrhage. Obstruction of airflow is often the effect caused by tissue edema narrowing the passageways and mucus/blood/fluid impeding airflow.

  • Option B: Patients with carbon monoxide poisoning may exhibit hypotension. As carboxyhemoglobin (COHgb) levels rise, the cerebral blood vessels dilate, and both coronary blood flow and capillary density increases. Cardiac effects, especially ventricular arrhythmias occur. Ventricular arrhythmias are implicated as the cause of death most often in CO poisoning.
  • Option C: Most commonly, patients with carbon monoxide poisoning will present with headache (more than 90%), dizziness, weakness, and nausea. Patients may be tachycardic and tachypneic. 
  • Option D: Patients may have systemic symptoms like a headache, delirium, hallucinations, and may even be comatose. Many different etiologies may cause changes in mental status including hypoxia, hypercarbia, or asphyxiant exposure (carbon monoxide, hydrogen cyanide). But headaches can also be seen with carbon monoxide poisoning.

NURSESLABS-BURNINJURY-02-008

Which finding indicates that fluid resuscitation has been successful for a client with a burn injury?

  • A. Hematocrit = 60%
  • B. Heart rate = 130 beats/min
  • C. Increased peripheral edema
  • D. Urine output = 50 mL/hr

Correct Answer: D. Urine output = 50 mL/hr

The fluid remobilization phase improves renal blood flow, increases diuresis, and restores blood pressure and heart rate to more normal levels, as well as laboratory values. This phase occurs on days 1-3 and requires an accurate fluid resuscitation and thorough evaluation for other injuries and comorbid conditions.

  • Option A: Hematocrit can indirectly reflect the resuscitation effect in the burn shock stage. Whether hematocrit level can be lowered to 0.45-0.50 during the first 24 hours after burn may be an important index for evaluation of fluid resuscitation effect in the early shock stage after severe burn.
  • Option B: The average daily heart rate was elevated in burn patients up to two years post-burn. Heart rate was elevated despite any afforded resuscitative efforts. While research data are up to two years post-injury, the heart rate of severely burned children was still 120% of predicted compared to normal values for children.
  • Option C: Swelling tends to occur soon after injury and generally decreases after 48–72 hours, although this timescale can vary. The extent and location of the swelling will depend on how the burn was caused and the location and depth of the burn injury. It is very important that the swelling is reduced as soon as possible.

NURSESLABS-BURNINJURY-02-009

Which finding indicates to the nurse that a client with a burn injury has a positive perception of his appearance?

  • A. Allowing family members to change his dressings
  • B. Discussing future surgical reconstruction
  • C. Performing his own morning care
  • D. Wearing the pressure dressings as ordered

Correct Answer: C. Performing his own morning care

Indicators that the client with a burn injury has a positive perception of his appearance include the willingness to touch the affected body part. Self-care activities such as morning care foster feelings of self-worth, which are closely linked to body image.

  • Option A: Encourage the patient and SO to view wounds and assist with care as appropriate. This promotes acceptance of the reality of injury and of change in body and image of self as different.
  • Option B: Discussing future reconstruction would not indicate a positive perception of appearance. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.
  • Option D: Wearing the dressing will assist in decreasing complications, but will not increase self-perception. However, give positive reinforcement of progress and encourage endeavors toward attainment of rehabilitation goals. Words of encouragement can support the development of positive coping behaviors.

NURSESLABS-BURNINJURY-02-010

Which finding indicates to the nurse that the client understands the psychosocial impact of his severe burn injury?

  • A. “It is normal to feel depressed.”
  • B. “I will be able to go back to work immediately.”
  • C. “I will not feel anger about my situation.”
  • D. “Once I get home, things will be normal.”

Correct Answer: A. “It is normal to feel depressed.”

During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.

  • Option B: Assist the patient and the family to express their feelings of grief and guilt. The patient and the family may initially be most concerned about the patient’s death and/or feel guilty, believing that in some way they could have prevented the incident.
  • Option C: Acknowledge and accept the expression of feelings of frustration, dependency, anger, grief, and hostility. Note withdrawn behavior and use of denial. Acceptance of these feelings as a normal response to what has occurred facilitates resolution. It is not helpful or possible to push the patient before ready to deal with the situation.
  • Option D: Assist the patient to identify the extent of actual change in appearance and body function. Feelings of grief, loss, anxiety, anger, fear, and guilt are all normal feelings that can occur. Clients need to know that problems of physical care and psychological stresses may be overwhelming.

NURSESLABS-BURNINJURY-02-011

Which finding is characteristic during the emergent period after a deep full-thickness burn injury?

  • A. Blood pressure of 170/100 mm Hg
  • B. Foul-smelling discharge from wound
  • C. Pain at site of injury
  • D. Urine output of 10 mL/hr

Correct Answer: D. Urine output of 10 mL/hr

During the fluid shift of the emergent period, blood flow to the kidney may not be adequate for glomerular filtration. As a result, urine output is greatly decreased. Urine output of 0.5 mL/kg or about 30 – 50 mL/hr in adults and 0.5-1.0 mL/kg/hr in children less than 30kg is a good target for adequate fluid resuscitation.

  • Option A: Blood pressure is usually low. During this inflammatory response, there is fluid loss that can cause a sharp and potentially deadly drop in blood pressure known as shock.
  • Option B: A foul-smelling discharge does not occur during the emergent phase. Third-degree involves the full thickness of skin and subcutaneous structures. It appears white or black/brown. With pressure, no blanching occurs. The burn is leathery and dry. 
  • Option C: Pain does not occur with deep full-thickness burns. There is minimal to no pain because of decreased sensation. Full-thickness burns heal by contracture and take greater than 8 weeks. Full-thickness burns require skin grafting.

NURSESLABS-BURNINJURY-02-012

Which is the priority nursing diagnosis during the first 24 hours for a client with chemical burns to the legs and arms that are red in color, edematous, and without pain?

Correct Answer: A. Decreased Tissue Perfusion 

During the emergent phase, fluid shifts into interstitial tissue in burned areas. When the burn is circumferential on an extremity, the swelling can compress blood vessels to such an extent that circulation is impaired distal to the injury, causing decreased tissue perfusion and necessitating the intervention of an escharotomy. 

  • Option B: Disturbed body image can develop. Assist the patient to identify the extent of actual change in appearance and body function. This helps begin the process of looking to the future and how life will be different.
  • Option C: Disuse syndrome can develop. Risk for disuse syndrome may be related to the physiological changes brought about by physical inactivity. These changes may include a decrease in muscle strength, limited joint movement, and loss of bone density. However, this is not a priority diagnosis at this time.
  • Option D: Chemical burns do not cause inhalation injury and a disrupted breathing pattern. The most common findings represent structural changes to the tissue directly affected, for example, the eye, oral mucosa, skin, esophagus, and lower intestinal system, especially the stomach and pylorus, respiratory system, among others.

NURSESLABS-BURNINJURY-02-013

Which laboratory result, obtained on a client 24 hours post-burn injury, will the nurse report to the physician immediately?

  • A. Arterial pH, 7.32
  • B. Hematocrit, 52%
  • C. Serum potassium,7.5 mmol/L (mEq/L)
  • D. Serum sodium, 131 mmol/L (mEq/L)

Correct Answer: C. Serum potassium,7.5 mmol/L (mEq/L)

The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in the potassium level, the client is at high risk of experiencing severe cardiac dysrhythmias and death. 

  • Option A: Acid-base studies were carried out on 76 consecutive burn patients admitted within 36 hours of injury. Admission blood pH and base excess (BE) values all decreased in a linear relationship to the extent of the burn. Blood Pco-2 changes were unrelated to the extent of the burn. Significant acidosis developed within 2 hours of burn injury.
  • Option B: The hematocrit (Hct) is the percentage of the volume of the whole blood that is made up of red blood cells. In burns, the patient has lost a lot of fluid from leaky blood vessels. There are more red cells than fluid so the hematocrit is high.
  • Option D: Serum sodium is abnormal, but not to the same degree of severity, and would be expected in the emergent phase after a burn injury. Severe cutaneous injuries such as burn injuries and blast injuries result in the loss of both water and sodium. For burn patients, hypernatremia that occurs within a few days of injury may be associated with increased risk of death.

NURSESLABS-BURNINJURY-02-014

Which nursing intervention is likely to be most helpful in providing adequate nutrition while the client is recovering from a thermal burn injury?

  • A. Allowing the client to eat whenever he or she wants.
  • B. Beginning parenteral nutrition high in calories.
  • C. Limiting calories to 3000 kcal/day.
  • D. Providing a low-protein, high-fat diet.

Correct Answer: A. Allowing the client to eat whenever he or she wants.

Clients should request food whenever they think that they can eat, not just according to the hospital’s standard meal schedule. Ascertain food likes and dislikes. Encourage SO to bring food from home, as appropriate. This provides the patient or SO a sense of control; enhances participation in care and may improve intake.

  • Option B: Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications. Total parenteral nutrition (TPN) maintains nutritional intake and meets metabolic needs in presence of severe complications or sustained esophageal or gastric injuries that do not permit enteral feedings.
  • Option C: Clients who can eat solid foods should ingest as many calories as possible. Appropriate guides to proper caloric intake include 25 kcal/kg body weight, plus 40 kcal per percentage of TBSA burn in the adult. As the burn wound heals, the percentage of burned areas is reevaluated to calculate prescribed dietary formulas, and appropriate adjustments are made.
  • Option D: The nurse needs to work with a nutritionist to provide a high-calorie, high-protein diet to help with wound healing. Refer to a dietitian or nutrition support team. This may be useful in establishing individual nutritional needs (based on weight and body surface area of injury) and identifying appropriate routes.

NURSESLABS-BURNINJURY-02-015

Which statement best exemplifies the client’s understanding of rehabilitation after a full-thickness burn injury?

  • A. “I am fully recovered when all the wounds are closed.”
  • B. “I will eventually be able to perform all my former activities.”
  • C. “My goal is to achieve the highest level of functioning that I can.”
  • D. “There is never full recovery from a major burn injury.”

Correct Answer: C. “My goal is to achieve the highest level of functioning that I can.”

Although a return to pre-burn functional levels is rarely possible, burned clients are considered fully recovered or rehabilitated when they have achieved their highest possible level of physical, social, and emotional functioning. The technical rehabilitative phase of rehabilitation begins with wound closure and ends when the client returns to her or his highest possible level of functioning.

  • Option A: The final stage in caring for a patient with a burn injury is the rehabilitative stage. This stage starts with the closure of the burn and ends when the patient has reached the optimal level of functioning. The focus is on helping the patient return to a normal injury-free life. Helping the patient adjust to the changes the injury has imposed is also a priority.
  • Option B: Early compliance is essential to ensure the best possible long-term outcome and also to ease pain and assist with exercise regimes. Patients need to adhere to a positioning regime in the early stages of healing and this takes teamwork and dedication.
  • Option D: Rehabilitation of burns patients is a continuum of active therapy starting from admission. There should be no delineation between an ‘acute phase’ and a ‘rehabilitation phase’ as this idea can promote the inequality of secondary disjointed scar management and/or functional rehabilitation teams.

NURSESLABS-BURNINJURY-02-016

Which statement indicates that a client with facial burns understands the need to wear a facial pressure garment?

  • A. “My facial scars should be less severe with the use of this mask.”
  • B. “The mask will help protect my skin from sun damage.”
  • C. “This treatment will help prevent infection.”
  • D. “Using this mask will prevent scars from being permanent.”

Correct Answer: A. “My facial scars should be less severe with the use of this mask.”

The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Hypertrophic burn scars pose a challenge for burn survivors and providers. In many cases, they can severely limit a burn survivor’s level of function, including work and recreational activities.

  • Option B: Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. A widespread modality of prevention and treatment of hypertrophic scarring is the utilization of pressure garment therapy (PGT).
  • Option C: The pressure garment will not alter the risk of infection. At present, PGT is the standard first-line therapy for hypertrophic burn scars in many centers due to its non-invasive characteristics and presumed desirable treatment effects with few associated complications.
  • Option D: Scars will still be present. This treatment modality continues to be a clinically accepted practice. It is the most common therapy used for the treatment and prevention of abnormal scars after burn injury particularly in North America, Europe and Scandinavia where it is considered routine practice and regarded as the preferred conservative management with reported thinning and better pliability ranging from 60% to 85%.

NURSESLABS-BURNINJURY-02-017

The client with a dressing covering the neck is experiencing some respiratory difficulty. What is the nurse’s initial action?

  • A. Administer oxygen.
  • B. Loosen the dressing.
  • C. Notify the emergency team.
  • D. Document the observation as the only action.

Correct Answer: B. Loosen the dressing

Respiratory difficulty can arise from external pressure. The first action in this situation would be to loosen the dressing and then reassess the client’s respiratory status. Generally, it is recommended that pressure should be maintained between 20 and 30 mm Hg, which is above capillary pressure but less than what would diminish peripheral blood circulation.

  • Option A: It is unnecessary to administer oxygen. Wearing pressure garments is uncomfortable and challenging; problems with movement, appearance, fit, comfort, swelling of extremities, rashes, and blistering are common; consequently, low compliance with PGT is to be expected.
  • Option C: The nurse may intervene first. However, monitoring of pressure exerted by pressure garments is currently difficult and time-consuming, and not routinely done and currently, the optimal pressure magnitude for PGT remains unsolved.
  • Option D: The nurse may loosen the dressing to help the client breathe. Recent evidence suggests that pressure garment therapy is effective for the prevention and/or treatment of abnormal scarring after burn injury but that the clinical benefit is restricted to those patients with moderate or severe scarring.

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NURSESLABS-BURNINJURY-02-018

During the acute phase, the nurse applied gentamicin sulfate (topical antibiotic) to the burn before dressing the wound. The client has all the following manifestations. Which manifestation indicates that the client is having an adverse reaction to this topical agent?

  • A. Increased wound pain 30 to 40 minutes after drug application
  • B. Presence of small, pale pink bumps in the wound beds
  • C. Decreased white blood cell count
  • D. Increased serum creatinine level

Correct Answer: D. Increased serum creatinine level

Gentamicin is nephrotoxic and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Characteristically, gentamicin reaches high concentrations in the renal cortex and the inner ear. 

  • Option A: Gentamicin does not stimulate pain in the wound. The gentamicin is prone to accumulate in the renal proximal tubular cells and can cause damage. Hence, mild proteinuria and reduction of the glomerular filtration rate are potential consequences of gentamicin use, achieving 14% of gentamicin users in a review.
  • Option B: The small, pale pink bumps in the wound bed are areas of re-epithelialization and not an adverse reaction. Renal function should be evaluated twice-weekly in patients without previous renal disease through serum creatinine and blood urea nitrogen. Periodic microscopic urinalysis is also vital to detect proteinuria and casts, which may indicate kidney injury.
  • Option C: The possible hypersensitivity manifestations of gentamicin are urticaria, eosinophilia, delayed-type hypersensitivity reaction (Stevens-Johnson syndrome and toxic epidermal necrolysis), angioedema, and anaphylactic shock. The clinical manifestations should guide the treatment strategy.

NURSESLABS-BURNINJURY-02-019

Which intervention is most important to use to prevent infection by autocontamination in the burned client during the acute phase of recovery?

  • A. Changing gloves between wound care on different parts of the client’s body.
  • B. Avoiding sharing equipment such as blood pressure cuffs between clients.
  • C. Using the closed method of burn wound management.
  • D. Using proper and consistent handwashing.

Correct Answer: A. Changing gloves between wound care on different parts of the client’s body

Autocontamination is the transfer of microorganisms from one area to another area of the same client’s body, causing infection of a previously uninfected area. Use gowns, gloves, masks, and strict aseptic techniques during direct wound care and provide sterile or freshly laundered bed linens or gowns.

  • Option B: Although all techniques listed can help reduce the risk of infection, only changing gloves between carrying out wound care on different parts of the client’s body can prevent autocontamination. Depending on the type or extent of wounds and the choice of wound treatment (open versus closed), isolation may range from a simple wound and/or skin to complete or reverse to reduce the risk of cross-contamination and exposure to multiple bacterial flora.
  • Option C: Prevent skin-to-skin surface contact (wrap each burned finger or toe separately; do not allow burned ear to touch scalp). This identifies the presence of healing (granulation tissue) and provides for early detection of burn-wound infection. Infection in a partial-thickness burn may cause conversion of burn to full-thickness injury.
  • Option D: Emphasize and model good handwashing techniques for all individuals coming in contact with the patient. This prevents cross-contamination and reduces the risk of acquired infection.

NURSESLABS-BURNINJURY-02-020

The burned client relates the following history of previous health problems. Which one should alert the nurse to the need for alteration of the fluid resuscitation plan?

Correct Answer: C. Myocardial infarction 1 year ago.

It is likely the client has a diminished cardiac output as a result of the old MI and would be at greater risk for the development of congestive heart failure and pulmonary edema during fluid resuscitation.

  • Option A: Asthma is a chronic inflammatory disease of the airways, characterized by recurrent episodes of airflow obstruction resulting from edema, bronchospasm, and increased mucus production. Commonly associated with seasonal allergies (allergic rhinitis) and eczema (atopic dermatitis), these three conditions form what is known as the atopic triad.
  • Option B: The incubation period of an acute hepatitis B virus infection is approximately 12 weeks, with a majority of patients experiencing mild illness and less than 1% experiencing fulminant hepatic failure. After acute infection resolves, the majority of adult patients and a small percentage of infected infants develop antibodies against the hepatitis B surface antigen and end up recovering fully.
  • Option D: Nephrolithiasis, or kidney stones, is the most common condition affecting the urinary system, affecting about 12% of the world population, with a yearly incidence of 600,000 in America. It is the result of a crystal or crystalline concretion traveling from the kidney through the genitourinary system.
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