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 ["A","B","C"]

Explanation

Choice A Reason: This is a correct choice. Trying to avoid scratching is an advice that the nurse will provide to the client, as it prevents further damage and infection of the skin. Scratching can break the skin barrier and introduce bacteria or fungi into the wound, leading to inflammation and complications.

Choice B Reason: This is a correct choice. Applying a moist cool compress is an advice that the nurse will provide to the client, as it soothes and relieves itching and swelling. A moist cool compress can reduce inflammation and histamine release, which are responsible for allergic symptoms.

Choice C Reason: This is an incorrect choice. Using alcohol to cleanse the area is not an advice that the nurse will provide to the client, as it irritates and dries out the skin. Alcohol can strip away the natural oils and moisture from the skin, making it more prone to cracking and itching.

Choice D Reason: This is an incorrect choice. Using a wooden stick to scratch lesions is not an advice that the nurse will provide to the client, as it causes more harm than good. A wooden stick can injure or infect the skin, as well as spread the allergen or irritant to other areas.

Choice E Reason: This is a correct choice. Avoiding hot air is an advice that the nurse will provide to the client, as it aggravates itching and inflammation. Hot air can increase blood flow and histamine release, which are responsible for allergic symptoms. The client should also avoid hot water or showers, as they can have the same effect.

A. Obtain the client's blood glucose every 12 hr. B. Change the IV site dressing every 4 days. C. Change the IV tubing every 24 hr. D. Weigh the client every other day.

Correct Answer is C

Explanation

Choice A Reason: Obtaining the client's blood glucose every 12 hr is not enough, as the nurse should monitor it more frequently, at least every 4 to 6 hr, to prevent hyperglycemia or hypoglycemia. TPN is a high-glucose solution that can affect the blood sugar levels.

Choice B Reason: Changing the IV site dressing every 4 days is not enough, as the nurse should change it daily or as needed to prevent infection. TPN is a high-risk solution that can introduce microorganisms into the bloodstream.

Choice C Reason: This is the correct choice. Changing the IV tubing every 24 hr is recommended to prevent infection and maintain sterility. TPN is a complex solution that can support bacterial growth and contamination.

Choice D Reason: Weighing the client every other day is not enough, as the nurse should weigh the client daily to evaluate fluid balance and nutritional status. TPN can cause fluid retention or depletion, as well as weight gain or loss.

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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 client who is suffering from an allergic reaction asks the nurse what can be done about the itching. Which of the following will the nurse provide to the client?

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Explanation

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Correct Answer is C

Explanation

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