A nurse is caring for a client 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?
"A piece of healthy skin will be removed from an unburned area and grafted over the burned area."
"This procedure involves placing the client into a Whirlpool tub and removing the dead tissue."
"Dead tissue will be non-surgically removed."
"Incisions will be made in the burnt tissues to improve circulation."
The Correct Answer is D
A. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area.": This describes a skin graft, not escharotomy.
B. "This procedure involves placing the client into a Whirlpool tub and removing the dead tissue.": This describes hydrotherapy or wound debridement.
C. "Dead tissue will be non-surgically removed.": Describes enzymatic or mechanical debridement.
D. "Incisions will be made in the burnt tissues to improve circulation.": Escharotomy relieves pressure caused by tight, burned skin (eschar) to restore blood flow and prevent compartment syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.
B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.
C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.
D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.
Correct Answer is C
Explanation
A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.
B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.
C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.
D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.
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