A child has presented to the ER after a burn injury from a hot soup spill.
Blistering of area
Dry crusting surface
Intact skin surface
Blanching of wound area
Pain at wound site
Correct Answer : A,D,E
A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.
B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.
C. Intact skin surface: The skin is not intact; it is damaged and blistered.
D. Blanching of wound area: Indicates intact capillary refill and superficial depth.
E. Pain at wound site: Nerve endings are exposed, making these burns very painful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Evaluating the patient's level of pain after medication administration: This is important but comes after the medication is given.
B. Ensuring a bag valve mask (BVM) is at the bedside: Opioids and sedatives depress respiratory drive. Emergency resuscitation equipment (like a BVM) must be ready in case of respiratory compromise.
C. Verification of allergies to medications: Important, but verifying allergies should already be done before administering any meds; not the priority here.
D. Documenting the level of pain before medication administration: Also important, but secondary to safety preparation.
Correct Answer is D
Explanation
A. Bleeding may occur at injection sites when the intramuscular route is used: While possible, this is not the primary concern.
B. The client can experience nausea and vomiting when given oral medications: This may be true but is secondary to absorption issues.
C. Pain resulting from a burn injury requires relief by the fastest route available: Although IV is fast, the key issue is absorption.
D. Damaged tissue and edema may interfere with drug absorption via other routes: Burned and edematous tissue reduces IM and subcutaneous absorption, making IV the preferred route.
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