Integumentary (Burns)

Question 1

During a first aid class, the nurse instructs clients on the emergency care of partial thickness burns. The nurse identifies which of the following interventions for partial thickness burns of the chest and arms BEST prevents infection?

1. Wash the burn with an antiseptic soap and water.
2. Remove clothing, and wrap the victim in a clean sheet.
3. Leave the blisters intact and apply an ointment.
4. Take no action until the victim arrives in a burn unit.

Answer 1

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Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired?

(1) soaps and ointments should not be applied to second-degree burns in an emergency situation
(2) correct—after fire is out, remove clothing and cover victim with a clean sheet
(3) soaps and ointments should not be applied to second-degree burns in an emergency situation
(4) does not prevent infection

Question 2

The nurse cares for clients on the medical/surgical unit. The nurse identifies which of the following clients is MOST at risk for developing herpes zoster?

1. A 19-year-old with a broken tibia in Buck's traction.
2. A 50-year-old with a diabetic foot ulcer.
3. A 62-year-old heart transplant with suspected rejection.
4. An 84-year-old with chronic obstructive pulmonary disease.

Answer 2

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Strategy:

(1) has an acute trauma, is not immunocompromised
(2) has a bacterial infection, is not immunocompromised
(3) correct—immunocompromised due to immune suppression therapy; clients with compromised immune system at risk for reactivation of the varicella zoster virus
(4) has chronic disease, is not immunocompromised