The nurse debriding a burn wound explains that the purpose of debridement is to:

increase the effectiveness of the skin graft.

promote movement in the affected area.

prevent infection and promote healing.

promote suppuration of the wound.

Answer and Explanation

The Correct Answer is C

A. Increase the effectiveness of the skin graft:

Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.

B. Promote movement in the affected area:

While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.

C. Prevent infection and promote healing:

This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.

D. Promote suppuration of the wound:

Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.

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Correct Answer is ["E"]

Explanation

A. Increased pulse rate:

This is a common manifestation of fluid overload. Excess fluid volume can lead to an increase in cardiac output, causing the heart to pump faster and resulting in an increased pulse rate.

B. Decreased blood pressure:

Fluid overload typically leads to increased blood volume, which can initially cause an increase in blood pressure. However, as fluid overload progresses, it can lead to fluid redistribution, venous congestion, and decreased systemic vascular resistance, ultimately resulting in decreased blood pressure.

C. Skeletal muscle weakness:

Skeletal muscle weakness is not a direct manifestation of fluid overload. It is more commonly associated with electrolyte imbalances, such as hypokalemia or hypomagnesemia, which can occur as a consequence of fluid shifts but are not specific to fluid overload itself.

D. Warm and pink skin:

Warm and pink skin is not typically associated with fluid overload. Instead, it is more indicative of adequate tissue perfusion and oxygenation. In fluid overload, skin changes may include edema, cool and clammy skin due to venous congestion, or signs of skin breakdown in areas of pressure.

E. Distended neck veins:

Distended neck veins, specifically jugular venous distention (JVD), are commonly seen in patients with fluid overload, especially if there is right-sided heart failure or increased central venous pressure. JVD is a result of increased venous return to the heart due to fluid accumulation.

A. Morbidly obese patient B. A woman who smokes and takes oral contraceptives or smoke C. Wheelchair-bound patient D. Patient with a humerus fracture E. Patient who underwent a prolonged surgical procedure

Correct Answer is ["A","B","E"]

Explanation

A. Morbidly obese patient: Obesity is a known risk factor for VTE due to several reasons. Morbidly obese individuals often have impaired mobility, which can lead to venous stasis (sluggish blood flow in the veins). Additionally, obesity is associated with inflammation and changes in blood clotting factors, increasing the risk of developing blood clots in the veins.

B. A woman who smokes and takes oral contraceptives or smokes: Both smoking and oral contraceptive use are independent risk factors for VTE. Smoking can cause damage to blood vessels and alter blood clotting mechanisms, while oral contraceptives can increase the risk of blood clots due to hormonal changes.

C. Wheelchair-bound patient: While being wheelchair-bound alone may not always indicate a high risk for VTE, immobility is a significant risk factor for developing blood clots. Prolonged periods of immobility can lead to blood stasis in the veins, making wheelchair-bound patients susceptible to VTE, especially if other risk factors are present.

D. Patient with a humerus fracture: A humerus fracture on its own may not necessarily increase the risk of VTE significantly. However, if the fracture requires immobilization or surgery, especially if it affects the lower extremities or leads to prolonged immobility, the risk of VTE can increase due to decreased blood flow and stasis.

E. Patient who underwent a prolonged surgical procedure: Prolonged surgical procedures often involve anesthesia, immobility during surgery, and postoperative immobilization, all of which can contribute to venous stasis and increase the risk of developing VTE. Additionally, the surgical trauma itself can trigger inflammatory responses and alterations in blood clotting factors, further elevating the risk of blood clots.

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The nurse debriding a burn wound explains that the purpose of debridement is to:

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A nurse assesses a patient who is admitted for treatment of fluid overload. Which manifestations does the nurse expect to find? (Select all that apply.)

Correct Answer is ["E"]

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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