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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.

B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.

C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.

D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.

A. A combination of benzodiazepines and topical anesthetics B. The use of oral opioids C. A patient-controlled analgesia (PCA) system D. Distraction and relaxation techniques

Correct Answer is C

Explanation

A. A combination of benzodiazepines and topical anesthetics: This is not effective for the deep and constant pain experienced with burns.

B. The use of oral opioids: Absorption may be delayed or unpredictable in critically ill burn clients.

C. A patient-controlled analgesia (PCA) system: PCA provides rapid and individualized control of pain, which is essential in the acute phase.

D. Distraction and relaxation techniques: These are supportive, not primary, strategies for severe pain.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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