Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1

Detailed Answer Key RN 231 Quiz 4_Cloned_Assessment 1 1. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should be aware that initially the client is at greatest risk for A. airway obstruction. Rationale: Burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care. B. infection. Rationale: Although prevention of infection is an important aspect of burn care throughout hospitalization and treatment, there is a greater initial priority for this client. C. fluid imbalance. Rationale: Although adequate fluid replacement is an important aspect of burn care throughout the acute phase of burn treatment, there is a greater initial priority for this client. D. paralytic ileus. Rationale: Although paralytic ileus may occur during the acute phase aspect of burn care and may require nasogastric suctioning, there is a greater initial priority for this client. 2. A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is pending an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate? A. "Large incisions will be made in the eschar to improve circulation." Rationale: An escharotomy is a surgical incision made to release pressure and improve circulation in a part of the body that has a deep burn and is experiencing excessive swelling. Burn injuries that encircle a body part, such as an arm or the chest, can cause swelling and tightness in the affected area, resulting in reduced circulation. Making surgical incisions into the burned tissue allows the skin to expand, reduces tightness and pressure, and improves circulation. B. "I can call the doctor back here if you want me to." Rationale: This is a nontherapeutic response that defers the client's concern and puts it on hold. C. "A piece of skin will be removed and grafted over the burned area." Rationale: A surgical procedure in which a piece of skin from one area of the client's body is transplanted to another area is called a skin graft. D. "Dead tissue will be surgically removed." Rationale: Debridement is the surgical removal of dead tissue.