Body Systems Questions & Answers, Rationales
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What type of wound drainage is clear and watery?
CORRECT ANSWER:
Serous drainage
What does serosanguineous drainage look like?
CORRECT ANSWER:
Pink/light red and thin
What is the clinical significance of sanguineous drainage?
CORRECT ANSWER:
Bright red, bloody; indicates fresh bleeding that should be reported if heavy
What type of drainage indicates infection?
CORRECT ANSWER:
Purulent drainage, which is yellow, green, brown, and may have a foul odor
What is the Parkland Formula for fluid resuscitation?
CORRECT ANSWER:
,4 mL x kg x %TBSA burned; administer 1/2 in first 8 hours, 1/4 in next 8 hours,
and 1/4 in final 8 hours
What is a common complication in the emergent phase of burns?
CORRECT ANSWER:
Burn shock due to massive fluid shift leading to hypovolemia
What is Curling's ulcer and its prevention?
CORRECT ANSWER:
A stress ulcer from burns; prevent with Protonix or H2 blockers
What is the priority complication of electrical burns?
CORRECT ANSWER:
Cardiac dysrhythmias; attach a cardiac monitor immediately
What is a key indicator of perfusion in burn patients?
CORRECT ANSWER:
Decreased urine output (<30 mL/hr)
What is the nursing consideration for silver sulfadiazine?
CORRECT ANSWER:
Do not use in patients with sulfa allergy; apply with gloves
What are the side effects of mafenide acetate?
CORRECT ANSWER:
Painful on application and can cause metabolic acidosis
What is the appearance and healing time for a superficial (1st degree) burn?
CORRECT ANSWER:
Red, dry, no blisters; heals in 3-5 days with possible scarring
What characterizes a partial thickness (2nd degree) burn?
CORRECT ANSWER:
Blistered, moist, pink/red; may require grafting
What is the appearance of a full thickness (3rd degree) burn?
,CORRECT ANSWER:
Dry, leathery, white/brown/black; painless due to nerve destruction
What is the rule of nines for estimating burn area in adults?
CORRECT ANSWER:
Head/Neck 9%, Each arm 9%, Chest 18%, Back 18%, Each leg 18%, Perineum 1%
What are the signs of burn shock?
CORRECT ANSWER:
Hypotension, tachycardia, decreased urine output, restlessness, cool clammy
skin
What is the nursing priority for post-op skin graft care?
CORRECT ANSWER:
Immobilization of the graft site to ensure adherence
What is the prodrome of Herpes Zoster (Shingles)?
CORRECT ANSWER:
Pain, burning, tingling before the rash appears along a dermatome
What type of isolation precautions are needed for Herpes Zoster?
CORRECT ANSWER:
Contact + airborne precautions for immunocompromised patients; contact
precautions for immunocompetent patients with localized lesions
What is a common delayed complication of electrical burns?
CORRECT ANSWER:
Cataracts, which may develop weeks to months later
What is the appearance of a deep (4th degree) burn?
CORRECT ANSWER:
Charred, black, painless; often requires amputation
What is the nursing consideration for morphine/fentanyl in burn patients?
CORRECT ANSWER:
, Only IV route is effective; IM/SQ absorption is unpredictable
What is the significance of rhabdomyolysis in electrical burns?
CORRECT ANSWER:
Muscle destruction releases myoglobin, which can block renal tubules and
cause acute kidney injury
What is the action of Acyclovir (Zovirax)?
CORRECT ANSWER:
Antiviral — reduces severity/duration of viral infections.
What are the key side effects of Acyclovir?
CORRECT ANSWER:
Nausea/vomiting (N/V), renal toxicity.
What nursing considerations are important for Acyclovir?
CORRECT ANSWER:
Hydrate well; monitor BUN/Cr; start within 72 hours of rash.
What is the preferred medication for better oral bioavailability in antiviral
treatment?
CORRECT ANSWER:
Valacyclovir (Valtrex).
What are the side effects of Valacyclovir?
CORRECT ANSWER:
Same as acyclovir.
What is the dosing option for Valacyclovir?
CORRECT ANSWER:
Once-daily dosing option.
What is Gabapentin (Neurontin) used for?
CORRECT ANSWER:
Postherpetic neuralgia pain.