Davis Edge Medical-Surgical Nursing:
Burns Exam 2025 Which clinical manifestations present in a client most likely indicates compartment syndrome? Select all that apply.
- Numbness
- Red-colored urine
- Diminishing pulse
- Complaints of pain with flexion
5. Urine output less than 1 mL/kg/hr - ANSWER>>ANSWERs: 1, 3, and 4 -
The client has a possibility of developing compartment syndrome in the first 48 hours post injury. Clinical manifestations of compartment syndrome include numbness in the involved extremities. Diminished pulse is a manifestation of compartment syndrome. If the client complains of pain with flexion or extension, it indicates compartment syndrome.
Rationales
Option 2: Red or tea colored urine indicates myoglobinuria which indicates
muscle damage.
Option 5: A client with myoglobinuria should be closely monitored for urine
output. If the urine output decreases, then fluid resuscitation should be performed, but this condition does not indicate compartment syndrome.
Page reference: 1107
Which type of skin graft may eventually require replacement by a permanent grafting?
- Autograft
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- Allograft
- Integra
- Cultured epithelial autograft
Test Taking Tip: This type of skin graft is used as a temporary coverage on
the burns. - ANSWER >> ANSWER : 2 - Allograft indicates a temporary
coverage as it will eventually need to be replaced by permanent grafting.
Rationales
Option 1: Autograft, indicating permanent coverage, is the ideal coverage
for all burn clients.
Option 3: Integra is used as a permanent coverage as it may provide a
functional dermis and better chance of wound closure.
Option 4: Cultured epithelial autograft is used as a permanent coverage,
and it is a good choice for a client with severe burns.
Page reference: 1118
Which condition of the client indicates deep partial-thickness burns?
- Minimal damage to the epidermis
- Damage to the entire epidermis and deeper layers of the dermis
- Damage to the entire epidermis and minimal damage to the dermis
- The damage would also involve subcutaneous fat and muscle, along
with dermis and epidermis - ANSWER>>ANSWER: 2 - In deep
partialthickness burns, or second degree burns, the entire epidermis and deeper layers of the dermis are damaged.
Rationales
- / 2