A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

"A cannula will be inserted into the bone to infuse fluids and antibiotics."

"An escharotomy surgically removes dead tissue."

"A piece of skin will be removed and grafted over the burned area."

"Large incisions will be made in the burned tissue to improve circulation."

Answer and Explanation

The Correct Answer is D

A. "A cannula will be inserted into the bone to infuse fluids and antibiotics.":
Describes intraosseous access, not escharotomy.

B. "An escharotomy surgically removes dead tissue.":
That is debridement, not escharotomy.

C. "A piece of skin will be removed and grafted over the burned area.":
Describes a skin graft, not escharotomy.

D. "Large incisions will be made in the burned tissue to improve circulation.":
Escharotomy involves cutting through the burned eschar to relieve pressure and restore circulation, especially in circumferential full-thickness burns.

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Correct Answer is A

Explanation

A. Allergic reaction in patients with sulfa allergies:
Silver sulfadiazine contains a sulfa compound and is contraindicated in patients with sulfonamide allergies.

B. Increased risk of infection:
Silver sulfadiazine is antimicrobial, and reduces infection risk, not increases it.

C. Delayed wound healing:
Some studies suggest it may delay epithelialization, but this is not the most common or concerning reaction.

D. Improved wound healing:
It helps prevent infection, but does not significantly accelerate healing. The focus is on infection control, not wound closure.

A. A shallow, ruptured or intact skin blister without slough B. Unbroken skin with un-blancheable erythema C. A deep crater without visible bone, tendon, or muscle D. Full-thickness tissue loss extending to underlying support structures

Correct Answer is C

Explanation

A. A shallow, ruptured or intact skin blister without slough:
Describes a Stage 2 pressure ulcer.

B. Unbroken skin with un-blancheable erythema:
This is a Stage 1 pressure ulcer.

C. A deep crater without visible bone, tendon, or muscle:
Correct. This describes a Stage 3 pressure ulcer with full-thickness tissue loss and subcutaneous damage.

D. Full-thickness tissue loss extending to underlying support structures:
This describes a Stage 4 pressure ulcer.

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A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

Nursing Test Bank

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Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Correct Answer is A

Explanation

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Correct Answer is C

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