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

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Burns NCLEX Question and Burn Injury Nursing Management Quiz #3 (20 Items)

NURSESLABS-BURNINJURY-03-001

Nurse Malcolm is performing a sterile dressing change on a client with a superficial partial-thickness burn on the shoulder and back. Arrange the steps in the order in which each should be performed.

  1. Administer Tramadol (Tramal) 50 mg IV.
  2. Debride the wound of eschar using gauze sponges.
  3. Obtain a sample for wound culture.
  4. Apply silver nitrate ointment.
  5. Cover the wound using a sterile gauze dressing.

The correct order is shown above 

Rationale:

  • Pain medication is administered prior to the dressing change since the type of burn will be painful during the procedure. Opioids may be required initially to control pain, but once first aid measures have been effective non-steroidal anti-inflammatory drugs such as ibuprofen or co-dydramol taken orally will suffice.
  • Then the wound is debrided before getting the sample for culture to prevent other bacteria that can contaminate the actual wound. It is important to realize that a new burn is essentially sterile, and every attempt should be made to keep it so. The burn wound should be thoroughly cleaned with soap and water or mild antibacterial wash such as dilute chlorhexidine.
  • Obtain a sample for wound culture. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury
  • An antibacterial cream such as silver nitrate is applied to the area to attain the maximum effect of the medication. Flamazine is silver sulfadiazine cream and is applied topically on the burn wound. It is effective against gram-negative bacteria including Pseudomonas.
  • Lastly, cover the wound using a sterile dressing. Depending on how healing is progressing, dressing changes thereafter should be every three to five days. If the Jelonet dressing has become adherent, it should be left in place to avoid damage to the delicate healing epithelium. If Flamazine is used it should be changed on alternate days.

NURSESLABS-BURNINJURY-03-002

Which of the following medications given to a 12-year-old client for the treatment of deep partial-thickness burn is the most important to double-check with another licensed nurse before administering it?

  • A. Aloe Vera Relief Burn spray.
  • B. Silver Sulfadiazine ointment.
  • C. Omeprazole 20 mg slow IV push.
  • D. Amitriptyline (Elavil) 50 mg PO.

Correct Answer: D. Amitriptyline (Elavil) 50 mg PO.

Amitriptyline (Elavil) is useful in the management of neuropathic pain following burn injury and since it is an antidepressant if given with a child, utmost precaution is given. The FDA has issued a black box warning regarding the use of amitriptyline in adolescents and young adults (ages less than 24 years). It can increase the risk of suicidal ideation and behavior.

  • Option A: Omeprazole is indicated for the short-term treatment of peptic ulcer disease in adults where most patients heal within four weeks.  Patients with duodenal ulcer disease and H. pylori infection disease that is active for up to one year may benefit from combination therapy that includes omeprazole with clarithromycin, amoxicillin, and metronidazole.
  • Option B: Silver sulfadiazine is a medication used in the prevention, management, and treatment of burn wound infections. It is a heavy metal topical agent with antibacterial properties. Typically burn dressings consist of topical silver sulfadiazine combined with fine mesh gauze and are usable in both the inpatient and outpatient settings.
  • Option C: All health facilities practice double-checking of medications prior to administration, Of all the medications given, Amitriptyline is the most important to double-check with another licensed nurse.

NURSESLABS-BURNINJURY-03-003

The nurse is administering fluids intravenously as ordered to a client who acquired a full-thickness burn injury on the abdomen. To determine the sufficiency of fluid resuscitation, the nurse would monitor which of the following would provide the most reliable parameter for determining adequacy?

  • A. Level of consciousness
  • B. Peripheral pulses
  • C. Urine output
  • D. Vital signs

Correct Answer: C. Urine output

Of all the options, urine output is the most reliable indicator for determining the adequacy of fluid resuscitation. 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: Heart rate, mental status, and capillary refill may be affected by the underlying disease process and are less reliable markers. The actual endpoint of fluid therapy in shock is to optimize tissue perfusion. However, this parameter is not measured directly. Surrogate endpoints include clinical indicators of end-organ perfusion and measurements of preload.
  • Option B: Because of compensatory vasoconstriction, mean arterial pressure (MAP) is only a rough guideline; organ hypoperfusion may be present despite apparently normal values. Because urine output does not provide a minute-to-minute indication, measures of preload may be helpful in guiding fluid resuscitation for critically ill patients.
  • Option D: Patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Recent literature has raised concerns about complications from over-resuscitation described as “fluid creep.” Again, adequate fluid resuscitation is the goal.

NURSESLABS-BURNINJURY-03-004

Nurse Rodrigo is receiving an endorsement from the burn unit. Which of the following clients should he assess first?

  • A. A client who has just been transferred from the PACU after having an allograft.
  • B. A client admitted 1 week ago with a superficial-thickness burn on the buttocks which has been waiting for 2 hours to receive discharge instructions.
  • C. A client who has just arrived from the emergency department with burns on the neck and chest.
  • D. A client with deep partial-thickness burns on both thighs who is complaining of severe and continuous pain.

Correct Answer: C. A client who has just arrived from the emergency department with burns on the neck and chest.

Burns of the neck and chest are associated with inflammation and swelling of the airway. Hence this patient requires the most immediate attention. Although a patient may be capable of spontaneous breathing in the early hours after a burn, compromise of the airway can still develop. This may be due to external pressure on the airway, with edema developing in the head and neck region, or in the upper airway due to inhalation of hot gases, including steam or aspiration of hot liquids.

  • Option A: Split-thickness grafts can cover the extensive defects created after scar release. These grafts will need meticulous attention to achieve complete and early wound closure, but thereafter prolonged splinting will be important to maintain release and prevent contracture.
  • Option B: In the superficial burn, wound dressings suffice. These can be biological or synthetic. Some medicated elements can prevent secondary infection. Superficial facial wounds can also be treated exposed, with or without the application of topical ointments.
  • Option D: Opioids may be given to this patient. These burns need to be shaved to preserve residual elements capable of regeneration. Burns of the face and neck rarely fall into aesthetic units, and professional judgment must determine how the excision should be performed. Grafting should be in aesthetic units if at all possible, and sheet grafts should be used on the face.

NURSESLABS-BURNINJURY-03-005

Which of the following routes should the nurse expect the pain medication to be given to a client who was admitted with extensive burns?

  • A. Oral
  • B. Intramuscular
  • C. Subcutaneous
  • D. Intravenous

Correct Answer: D. Intravenous

For clients with major burns, the intravascular route is the preferred choice of medication administration. Patient-controlled analgesia (PCA) with IV opioids is a safe and efficient method of achieving flexible analgesia in burn-injured patients. Studies comparing PCA with other routes of administration have shown mixed results as to benefit and patient satisfaction.

  • Option A: Oral NSAIDs and acetaminophen are mild analgesics that exhibit a ceiling effect in their dose-response relationship. Such limitations render these agents unsuitable for the treatment of typical, severe burn pain. Oral NSAIDS and acetaminophen are of benefit in treating minor burns, usually in the outpatient setting.
  • Option B: In intramuscular drug administration, the absorption of the drug is determined by the bulk of the muscle and its vascularity. The onset and duration of the action of the drug is not adjustable. In case of inadvertent scenarios such as anaphylaxis, burns, or neurovascular injuries, intravenous (IV) assess needs to be secured
  • Option C: Subcutaneous injections are another form of the parenteral route of medication and are administered to the layer of skin referred to as cutis, just below the dermis and epidermis layers. Subcutaneous tissue has few blood vessels; therefore, the medications injected undergo absorption at a slow, sustained rate.

NURSESLABS-BURNINJURY-03-006

Nurse Cirie is caring for a client who suffered a smoke inhalation injury. The carbon monoxide report reveals a level of 35%. Based on the level, which of the following signs should the nurse expect in the client?

Correct Answer: B. Confusion

Signs and symptoms of carbon monoxide levels between 21-40% (moderate poisoning) include hypotension, tachycardia, headache, drowsiness, confusion, nausea, and vomiting. Mental status changes such as altered level of consciousness, disorientation, and memory loss may occur.

  • Option A: Carbon monoxide levels of 41% to 60% result in seizures. As carboxyhemoglobin (COHgb) levels rise, the cerebral blood vessels dilate, and both coronary blood flow and capillary density increase. If exposure continues, central respiratory depression develops which may result from cerebral hypoxia.
  • Option C: Carbon monoxide levels of 11% to 20% result in flushing. The classic symptoms of cherry red nail beds and mucous membranes are not “classic” and are usually post-mortem findings. Patients may also develop ataxia, apraxia, incontinence, and cortical blindness.
  • Option D: Cardiac effects, especially ventricular arrhythmias occur. Ventricular arrhythmias are implicated as the cause of death most often in CO poisoning. There is evidence that myocardial impairment begins at the relatively low level of COHgb of 20%.

NURSESLABS-BURNINJURY-03-007

A client is brought to the emergency unit with third-degree burns on the posterior trunk, right arm, and left posterior leg. Using the Rule of Nines, what is the total body surface area that has been burned?

  • A. 36%
  • B. 54%
  • C. 45%
  • D. 27%

Correct Answer: A. 36%

The Rule of Nines, also known as the Wallace Rule of Nines, is a tool used by trauma and emergency medicine providers to assess the total body surface area (TBSA) involved in burn patients. Based on the rule of nines, the posterior trunk equals 18%, right arm equals 9%, and the left posterior leg equals 9%. Therefore, a total of 36%.

  • Option B: The Rule of Nines estimation of body surface area burned is based on assigning percentages to different body areas. The entire head is estimated as 9% (4.5% for anterior and posterior). The entire trunk is estimated at 36% and can be further broken down into 18% for anterior components and 18% for the back.
  • Option C: The anterior aspect of the trunk can further be divided into chest (9%) and abdomen (9%). The upper extremities total 18% and thus 9% for each upper extremity. Each upper extremity can further be divided into anterior (4.5%) and posterior (4.5%).
  • Option D: The lower extremities are estimated at 36%, 18% for each lower extremity. Again this can be further divided into 9% for the anterior and 9% for the posterior aspect. The groin is estimated at 1%.

NURSESLABS-BURNINJURY-03-008

A medicine student arrives at the emergency unit due to a burn injury that occurred inside the laboratory and an inhalation injury is suspected. Which of the following is the appropriate oxygen therapy for the client?

  • A. Oxygen via nasal cannula at 5 L/min.
  • B. Oxygen via a tight-fitting, non-rebreather face mask at 100% concentration.
  • C. Oxygen via nasal cannula at 10 L/min.
  • D. Oxygen via Venturi mask at 30% Fi02.

Correct Answer: B. Oxygen via a tight-fitting, non-rebreather face mask at 100% concentration.

If an inhalation injury is suspected, management includes the administration of oxygen via a tight-fitting, non-rebreather face mask at 100% concentration. This is prescribed until carboxyhemoglobin levels in the blood fall below 15%. Non-rebreathing masks have a bag attached to the mask known as a reservoir bag, which inhalation draws from to fill the mask through a one-way valve and features ports at each side for exhalation, resulting in an ability to provide the patient with 100% oxygen at a higher LPM flow rate.

  • Options A and C: The nasal cannula is a thin tube, often affixed behind the ears and used to deliver oxygen directly to the nostrils from a source connected with tubing. This is the most common method of delivery for home use and provides flow rates of 2 to 6 liters per minute (LPM) comfortably, allowing the delivery of oxygen while maintaining the patient’s ability to utilize his or her mouth to talk, eat, etc.
  • Option D: An air-entrainment (also known as venturi) mask can provide a pre-set oxygen to the patient using jet mixing. As the percent of inspired oxygen increases using such a mask, the air-to-oxygen ratio decreases, causing the maximum concentration of oxygen provided by an air-entrainment mask to be around 40%. 

NURSESLABS-BURNINJURY-03-009

The nurse is handling a client who sustained an electrical burn on the arm and wrist and is scheduled for a fasciotomy. After the procedure, the nurse should assess the affected extremity in which of the following, except?

  • A. Sensation
  • B. Color
  • C. Distal circulation
  • D. All of the above

Correct Answer: D. All of the above

Following fasciotomy, the nurse should assess pulses, color, sensation, and movement of the affected extremity as well as bleeding. A fasciotomy is an emergency procedure used to treat acute compartment syndrome. Acute compartment syndrome often follows high energy trauma, fractures, circumferential burns, crush injuries, or even a tight plaster cast.

  • Option A: Loss of sensation can signal compartment syndrome. Classical features of compartment syndrome are those of ischemia, pain out of proportion to the injury, paraesthesia, pallor, paralysis, and pain on passive movement, especially stretch of the concerned compartment. 
  • Option B: Pallor is associated with compartment syndrome. Fasciotomy wound management begins with an inspection at 48 hours. If the compartments are soft, this closure is achievable by primary wound closure, secondary wound healing, or as needed in approximately 50% of wounds split-thickness skin grafting. 
  • Option C: Distal circulation should be checked to prevent ischemia. Two-point discrimination can be useful for determining nerve ischemia. These signs and symptoms can be challenging to assess depending on the conscious level, sensory state, and ability to communicate.

NURSESLABS-BURNINJURY-03-010

The nurse is caring for a client with a burn wound on the left knee and an autograft and skin grafting was performed. Which of the following activities will be prescribed for the client post-op?

  • A. Elevation and immobilization of the affected leg.
  • B. Placing the affected leg in a dependent position.
  • C. Dangling of legs.
  • D. Bathroom privileges.

Correct Answer: A. Elevation and immobilization of the affected leg.

Autograft placed on the lower extremity requires elevation and immobilization for at least 3-7days. This period of immobilization allows the autograft time to adhere to the wound bed. Clinically, skin grafts are secured into place and often bolstered until postoperative day 5 to 7 to allow the skin graft to go through the above steps, ensuring the best skin graft take.

  • Option B: Do not place the affected leg in a dependent position. Any buildup of fluid between the split-thickness skin graft and wound bed will jeopardize skin graft take, including seroma, hematoma, and infection. Shear or traction injury also disrupts skin graft healing.
  • Option C: Dangling of legs puts the affected site into a dependent position, which can cause a build-up of fluid that jeopardizes the skin graft. The graft can have incomplete (less than 100%) take or complete nontake.
  • Option D: Split-thickness skin grafts typically become adherent to the recipient wound bed 5 to 7 days following skin graft placement. The dressings placed intraoperatively are kept in place until 5 to 7 days postoperatively to minimize shear and traction to the healing skin graft.

NURSESLABS-BURNINJURY-03-011

Nurse Troyzan has just received the change-of-shift report in the burn unit. Which of the following clients requires the most immediate care?

  • A. A 50-year-old who was admitted with electrical burns 24 hours ago and has a serum potassium level of 5 mEq/L.
  • B. A 40-year-old with partial-thickness leg burns which has a temperature of 101.9°F and blood pressure of 89/42 mm Hg.
  • C. A 30-year-old who returned from debridement surgery 3 hours ago and is complaining of pain (Pain scale of 7/10).
  • D. A 25-year-old admitted 4 days previously with facial burns due to a house fire and has been crying since recent visitors left.

Correct Answer: B. A 40-year-old with partial-thickness leg burns which has a temperature of 101.9°F and blood pressure of 89/48 mm Hg.

The client’s vital signs indicate that life-threatening complications of sepsis may be developing. Burn wound infections are one of the most important and potentially serious complications that occur in the acute period following injury. If the patient’s host defenses and therapeutic measures (including excision of necrotic tissue and wound closure) are inadequate or delayed, microbial invasion of viable tissue occurs, which is the hallmark of an invasive burn wound infection.

  • Option A: Classically, hyperkalemia has been regarded as a complication in patients with electrical burns. The etiology of hyperkalemia includes metabolic acidosis, destruction of red blood cells, rhabdomyolysis, and the development of renal failure.
  • Option C: Oral NSAIDs and acetaminophen are of benefit in treating minor burns, usually in the outpatient setting. For hospitalized burn patients, opioids are the cornerstone of pharmacologic pain control. Patient-controlled analgesia (PCA) with IV opioids is a safe and efficient method of achieving flexible analgesia in burn-injured patients.
  • Option D: Symptoms of depression and anxiety are common and start to appear in the acute phase of recovery. Acute stress disorder (occurs in the first month) and post-traumatic stress disorder (occurs after one month) are more common after burns than other forms of injury.

NURSESLABS-BURNINJURY-03-012

The nurse is caring for a client who sustained superficial partial-thickness burns on the anterior lower legs and anterior thorax. Which of the following does the nurse expect to note during the resuscitation/emergent phase of the burn injury?

  • A. Increased blood pressure
  • B. Increased hematocrit levels
  • C. Decreased heart rate
  • D. Increased urine output

Correct Answer: B. Increased hematocrit levels

The resuscitation/emergent phase begins at the time of injury and ends with the restoration of capillary permeability, usually at 48-72 hours following the injury. During this phase, there is an elevation of the hematocrit levels due to hemoconcentration from the large fluid shifts

  • Option A: Blood pressure is decreased due to the shifting of fluids. The acute phase of burns is defined as a period extending from the onset of burns with shock to the time taken for wound epithelialization which normally takes about 12 to 14 days if the management of burns is adequate. The first 48 is the period of shock.
  • Option C: Pulse rate is higher than normal. If resuscitation is carried out urgently the circulatory shock is not only prevented, none of the complications of shock are allowed to manifest.
  • Option D: Initially, blood is shunted away from the kidneys, resulting in low urine output. The greatest amount of fluid loss in burn patients is in the first 24 h after injury. For the first 8-12 hours, there is a general shift of fluids from intravascular to interstitial fluid compartments. This means that any fluid given during this time will rapidly leak out from the intravascular compartment.

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NURSESLABS-BURNINJURY-03-013

The nurse manager is observing a new nursing graduate caring for a burned client in protective isolation. The nurse manager intervenes if the new nursing graduate planned to implement which incorrect component of protective isolation technique?

  • A. Performing strict handwashing techniques.
  • B. Wearing protective garb, including a mask, gloves, cap, shoe covers, gowns, and a plastic apron.
  • C. Using sterile bed sheets and linens.
  • D. Wearing gloves and a gown only when giving direct care to the client.

Correct Answer: D. Wearing gloves and a gown only when giving direct care to the client.

Thorough hand washing is performed before and after each contact with the burn-injured client. During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces.

  • Option A: The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.
  • Option B: Protective garbs such as masks, gloves, caps, shoe covers, gowns, and a plastic apron need to be worn when having direct contact with the client. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination.
  • Option C: Sterile sheets and linen are used due to the high risk of infection. Soiled textiles, including bedding, towels, and patient or resident clothing may be contaminated with pathogenic microorganisms. However, the risk of disease transmission is negligible if they are handled, transported, and laundered in a safe manner.

NURSESLABS-BURNINJURY-03-014

A client is undergoing fluid replacement after being burned 20% of her body 12 hours ago. The nursing assessment reveals a blood pressure of 90/50 mm Hg, a pulse rate of 110 beats per minute, and a urine output of 25 ml over the past hour. The nurse reports the findings to the physician and anticipates which of the following orders?

  • A. Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour.
  • B. Transfusing 1 unit of packed red blood cells.
  • C. Administering diuretic to increase urine output.
  • D. Changing the IV lactated Ringer’s solution into dextrose in water.

Correct Answer: A. Increasing the amount of intravenous (IV) lactated Ringer’s solution administered per hour.

The client’s urine output indicates inadequate fluid resuscitation. Hence the physician would order an increased amount of lactated Ringer’s solution administered hourly. Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.” 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 B: Blood transfusion is not used for fluid resuscitation therapy unless there is an indication of a low hemoglobin level. This response, along with decreased cardiac output and increased vascular resistance, can lead to marked hypovolemia and hypoperfusion called “burn shock.” This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids.
  • Option C: Diuretic works by removing circulating volume, thereby further compromising the inadequate tissue perfusion. The patient’s vital signs, mental status, capillary refill, and urine output must be monitored and fluid rates adjusted accordingly. Again, adequate fluid resuscitation is the goal.
  • Option D: Dextrose in water will only maintain fluid balance since it is an isotonic solution, therefore will not be helpful in this situation. Four mL lactated ringers solution × percentage total body surface area (%TBSA) burned × patient’s weight in kilograms = total amount of fluid given in the first 24 hours.

NURSESLABS-BURNINJURY-03-015

Nurse Kelsey is a nurse manager assigned to the burn unit. Which client is best to assign to an RN who has floated from the surgery unit?

  • A. A client with infected partial-thickness back and chest burns who has a dressing scheduled.
  • B. A client who has just been admitted with burns over 30% of the body after a warehouse fire.
  • C. A client with full-thickness burns on both arms who needs assistance in positioning hand splints.
  • D. A client who requires discharge teaching about nutrition and wound care after having skin grafts.

Correct Answer: A. A client with infected partial-thickness back and chest burns who has a dressing scheduled.

Familiarity with the dressing change and practice of sterility by a nurse from the surgery unit will be appropriately used during the float in the burn unit. There are several options for burn dressings. Some are impregnated with antimicrobials (eg, silver). Most are a form of gauze, but there are biosynthetic dressings with some of the characteristics of skin that adhere to the wound and can be left in place for extended periods of time.

  • Option B:  Admission assessment requires expertise in caring for burn patients. The needs of the client must be competently met with the knowledge, skills and abilities of the staff to meet these needs. In other words, the nurse who delegates aspects of care to other members of the nursing team must balance the needs of the client with the abilities of those to which the nurse is delegating tasks and aspects of care.
  • Option C: Splinting requires expertise in caring for burn patients. The staff members’ levels of education, knowledge, past experiences, skills, abilities, and competencies are also evaluated and matched with the needs of all of the patients in the group of patients that will be cared for.
  • Option D: Discharge teaching requires expertise in caring for burn patients. Validated and documented competencies must also be considered prior to assignment of patient care. No aspect of care can be assigned or delegated to another nursing staff member unless this staff member has documented evidence that they are deemed competent by a registered nurse to do so.

NURSESLABS-BURNINJURY-03-016

A client sustained burns on the back. These areas appear dry, blotchy cherry red, blistering, doesn’t blanch, no capillary refill, and reduced or absent sensation. This type of burn depth is classified as?

  • A. Superficial partial-thickness burn
  • B. Superficial dermal
  • C. Deep partial-thickness burn
  • D. Full-thickness burn

Correct Answer: C. Deep partial-thickness burn

Deep partial-thickness burn: blistering, dry, blotchy cherry red, doesn’t blanch, no capillary refill, and reduced or absent sensation. Generally, heals in 3-6 weeks, but scar formation results and skin grafting may be required.

  • Option A: Superficial partial-thickness: red, glistening, pain, absence of blisters, and brisk capillary refill. Not life-threatening and normally heals within a week, without scarring. Superficial burns (first degree) involve only the epidermis and are warm, painful, red, soft, and blanch when touched. Usually, there is no blistering. A typical example is a sunburn.
  • Option B: Pale pink or mottled appearance with associated swelling and small blisters. A wet, shiny, and weeping surface is also a characteristic. Brisk capillary refill.
  • Option D: Full-thickness: dry, white, or black, no blisters, absent capillary refill, and absent sensation. Requires surgical repair and grafting. Full-thickness burns (third degree) extend through both the epidermis and dermis and into the subcutaneous fat or deeper. These burns have little or no pain, can be white, brown, or charred, and feel firm and leathery to palpation with no blanching.

NURSESLABS-BURNINJURY-03-017

Which of the following refers to a wound covering brought about by the donated human cadaver skin provided by the skin bank?

  • A. Autograft
  • B. Homograft
  • C. Heterograft
  • D. Xenograft

Correct Answer: B. Homograft

Homograft is a tissue graft from a donor of the same species as the recipient. Skin from organ donors can be used as a temporary covering. It is temporary because this skin will eventually be rejected. This is known as a homograft. Homografts may be required initially if the injured area is too large to be covered by the patient’s own skin.

  • Option A: A skin graft, also known as an autograft, involves taking skin from an unburned part of the patient’s body and placing it on the wound after the burn has been removed.
  • Option C: Pigskin grafts are termed xenografts, or heterografts because they are transplanted from an organism of one species to that of a different species. Both allografts and xenografts are biologic dressings only, are ultimately rejected by the patient’s immune system, and need to be removed prior to definitive wound treatment or skin grafting.
  • Option D: Xenograft is a graft of tissue taken from a donor of one species and grafted into a recipient of another species. While xenografts are rejected before undergoing revascularization, allografts initially undergo revascularization but are typically rejected after approximately 10 days because of the strong antigenicity of the skin.

NURSESLABS-BURNINJURY-03-018

A client is being discharged today after undergoing autografting. What would the nurse include in the discharge instructions?

  • A. Refrain from using splints.
  • B. Avoid smoking.
  • C. Exposed the site to sunlight.
  • D. Encourage weight-bearing exercise.

Correct Answer: B. Avoid smoking.

Smoking can decrease the blood supply to the newly graft recipient bed interface, and the chance of graft failure increases. The combined effect of nicotine and carbon monoxide is deadly to the healing process. This can result in partial or complete loss of healing of the wound, skin graft, flap, or any combination of these. This can compromise the cosmetic results of the surgery.

  • Option A: Static or primary splints are used in the acute phase for skin graft protection after surgery or anti contracture positioning. These splints are applied to adjacent intact skin.
  • Option C: Healed burns or skin grafts may be extremely sensitive to sunlight and may sunburn more severely even after short periods of time in the sun compared to before the injury. Sun sensitivity after a burn injury may last for a year or more.
  • Option D: At least 3 weeks after surgery, avoid exercise that stretches the skin graft, unless the doctor gives other instructions. If the graft was placed on the legs, arms, hands, or feet, the patient may need physiotherapy to prevent scar tissue from limiting movement.

NURSESLABS-BURNINJURY-03-019

A client is prescribed by the physician to undergo an escharotomy. Which of the following statements made by the nurse is true regarding this procedure?

  • A. “It is the surgical removal of a thin layer of the client’s own unburned skin.”
  • B. “A lengthwise incision is made through the burn eschar to relieve vasodilation.”
  • C. “It is performed at the bedside and without anesthesia.”
  • D. “It is the application of topical enzyme agents directly to the wound, and these agents digest necrotic collagen tissue.”

Correct Answer: C. “It is performed at the bedside and without anesthesia”.

An escharotomy is performed at the bedside and without anesthesia since nerve endings have been destroyed by the burn injury. An escharotomy is an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation.

  • Option A: A skin graft, also known as an autograft, involves taking skin from an unburned part of the patient’s body and placing it on the wound after the burn has been removed.
  • Option B: Escharotomy involves making a lengthwise incision through the burn eschar to relieve vasoconstriction. The incisions should extend from unburnt skin to unburnt skin ideally, or at least into areas of more superficial burns, down to subcutaneous fat, and release any constrictions.
  • Option D: This is a selective method for debridement of necrotic tissue using an exogenous proteolytic enzyme, collagenase, to debride Clostridium bacteria. Collagenase digests the collagen in the necrotic tissue allowing it to detach.

NURSESLABS-BURNINJURY-03-020

Rehabilitation is the final phase of burn care. Which of the following are the goals during this phase? Select all that apply.

  • A. Provide emotional support.
  • B. Prevent hypovolemic shock.
  • C. Promote wound healing and proper nutrition.
  • D. Fluid replacement.
  • E. Help the client in gaining optimal physical functioning.

Correct Answer: A, C, and E.

The rehabilitation phase starts after wound closure and ends upon discharge and beyond. The goals of this phase include minimizing functional loss, promoting psychosocial support, promoting wound healing, and proper nutrition.

  • Option A: Patients may try to refuse treatment as they are in pain and may not fully understand the impact of not participating in their rehabilitation; they, therefore, need the support and encouragement of the burn care professionals to help them through this difficult experience with the knowledge of how different their quality of life can be.
  • Option B: Inflammatory and vasoactive mediators such as histamines, prostaglandins, and cytokines are released causing a systemic capillary leak, intravascular fluid loss, and large fluid shifts. These responses occur mostly over the first 24 hours peaking at around six to eight hours after injury. This can be managed with aggressive fluid resuscitation and close monitoring for adequate, but not excessive, IV fluids.
  • Option C: Continuous monitoring and reassessment of nutritional status with modifications in nutritional therapy as indicated can accommodate the unique yet diverse needs of this population and support their therapeutic goals for recovery.
  • Option D: Belong to the main goal during the resuscitative phase. Patients with burns of more than 20% – 25% of their body surface should be managed with aggressive IV fluid resuscitation to prevent “burn shock.”
  • Option E: A comprehensive rehabilitation program is essential to decrease a patient’s post-traumatic effects and improve functional independence. While different professionals possess expertise in their own specialties, there are some simple and effective methods that can be utilized to help the patient reach their maximum functional outcome.
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