A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
"This procedure involves placing the client into a shower and removing the dead tissue."
"Dead tissue will be non-surgically removed."
"Large incisions will be made in the eschar to improve circulation."
"A piece of healthy skin will be removed from an unburned area and grafted over the burned area."
The Correct Answer is C
An escharotomy is a surgical procedure that involves making incisions in the eschar, which is the hard, blackened tissue that forms over a severe burn wound. The eschar can restrict blood flow and cause compartment syndrome, which can lead to tissue necrosis and nerve damage. By cutting through the eschar, the pressure is relieved and circulation is restored. This procedure does not involve removing the dead tissue, which is done by debridement or hydrotherapy. A skin graft is a different procedure that involves transplanting healthy skin from another site to cover a burn wound.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choiceD. Fresh flowers and potted plants in the room.
Choice A rationale:
While activities that could result in bleeding should be avoided in patients with low platelet counts, this is not directly related to neutropenia.Neutropenia primarily increases the risk of infection rather than bleeding.
Choice B rationale:
Restricting oral fluid intake to between meals is not relevant to managing neutropenia.Adequate hydration is important, but the timing of fluid intake does not impact neutropenia management.
Choice C rationale:
While limiting visitors can help reduce the risk of infection, it is not necessary to restrict all visitors.Instead, visitors should follow strict hygiene practices, such as handwashing and wearing masks, to minimize infection risk.
Choice D rationale:
Fresh flowers and potted plants can harbor bacteria and fungi, which pose a significant infection risk to neutropenic patients.Therefore, these should be avoided in the patient’s room.
Correct Answer is C
Explanation
This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.
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