A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

First degree

Second degree

Third degree

This burn cannot be classified

Answer and Explanation

The Correct Answer is A

Choice A Reason: This is correct because first degree burns are superficial burns that affect only the outer layer of the skin, called the epidermis. First degree burns cause redness, pain, and mild swelling, but no blisters or scarring. They usually heal within a week.

Choice B Reason: This is incorrect because second degree burns are partial thickness burns that affect both the epidermis and the underlying layer of the skin, called the dermis. Second degree burns cause blisters, severe pain, and possible infection. They may take several weeks to heal and may leave scars.

Choice C Reason: This is incorrect because third degree burns are full thickness burns that destroy all layers of the skin and may damage the underlying tissues, such as muscles, nerves, or bones. Third degree burns cause charred or white skin, numbness, and shock. They require skin grafting and may cause permanent disability or death.

Choice D Reason: This is incorrect because this burn can be classified according to the depth and extent of the skin damage. The classification of burns helps to determine the appropriate treatment and prognosis for the client.

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Correct Answer is D

Explanation

Choice A Reason: To administer medications and electrolytes is not the best reply for why the client will need the NG tube, because this is not the primary purpose of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Medications and electrolytes can be given through the IV route.

Choice B Reason: To dilate the stomach as a presurgical preparation is not the best reply for why the client will need the NG tube, because this is not a valid indication for the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. Dilation of the stomach is not a goal of presurgical preparation, but rather an adverse effect of gastric obstruction.

Choice C Reason: You will not be able to eat for several days is not the best reply for why the client will need the NG tube, because this is not a complete or accurate explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration. The client will not be able to eat for several days because of the NPO diet, which is necessary to rest the inflamed peritoneum and reduce the risk of complications.

Choice D Reason: To remove secretions and decompress your stomach is the best reply for why the client will need the NG tube, because this is a clear and correct explanation of the NG tube in this case. The NG tube is mainly used to relieve gastric distension and prevent vomiting and aspiration, which are common symptoms of acute peritonitis. By removing secretions and decompressing the stomach, the NG tube can reduce pain, inflammation, and infection in the abdominal cavity.

A. Report itching if it becomes bothersome B. Use earplugs when swimming C. Insert a cotton-tip applicator to remove excess wax D. Use a hairdryer set to low, 6 inches away from ear

Correct Answer is C

Explanation

Choice A Reason: Reporting itching if it becomes bothersome is part of client teaching, as it may indicate inflammation or infection of the ear canal. External otitis is also known as swimmer's ear, as it can be caused by water trapped in the ear after swimming or bathing.

Choice B Reason: Using earplugs when swimming is part of client teaching, as it can prevent water from entering and irritating the ear canal. External otitis can be prevented by keeping the ear dry and avoiding trauma or foreign objects.

Choice C Reason: This is the correct choice. Inserting a cotton-tip applicator to remove excess wax is not part of client teaching, as it can damage or scratch the ear canal and increase the risk of infection. Wax helps protect and lubricate the ear canal and should not be removed unless it causes hearing impairment or discomfort.

Choice D Reason: Using a hairdryer set to low, 6 inches away from ear is part of client teaching, as it can help dry the ear canal after swimming or bathing. External otitis can be treated by applying warm compresses, using topical antibiotics or antifungals, and taking pain relievers or anti-inflammatory drugs.

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A client arrives to the clinic after spending the day at the beach. She reports extreme pain and the nurse observes red skin on her face and upper body. There are no blisters present. What degree of burn has the client suffered?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with acute peritonitis reviews the physician's orders. The orders include an NPO diet, insertion of a nasogastric tube set to low intermittent suction, and IV fluids at 50 mL per hour. When asked why he will need the NG tube, what is the nurse's best reply?

Correct Answer is D

Explanation

A client presents to the clinic with complaints of otalgia and muffled sounds. The client is diagnosed with external otitis. Which of the following will the nurse not include in client teaching?

Correct Answer is C

Explanation

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider?

A nurse is preparing a client with extensive burns for hydrotherapy. What is the priority action by the nurse?

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A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?

A nurse is caring for a client who has progressive presbycusis. Which of the following actions should the nurse take?