A client presents with superficial burns and multiple intact blisters on the forearm.
During dressing change, several blisters rupture and the underlying skin is exposed. Which action should the nurse take?

Apply a topical antimicrobial ointment and sterile nonadherent dressing.

Leave the area open to air to promote drying.

Apply dry gauze tightly over the wound.

Remove all remaining intact blisters.

Answer and Explanation

The Correct Answer is A

This scenario requires understanding of integumentary integrity and burn wound management. Knowledge of infection prevention and moist wound healing principles is essential. Partial-thickness burns involve the epidermis and dermis, necessitating protection of the newly exposed, vulnerable basement membrane to facilitate re-epithelialization.

Choice A rationale

. Antimicrobials prevent colonization of exposed dermis while nonadherent dressings maintain a moist environment. This facilitates cellular migration and prevents further trauma during future dressing changes. Protecting the bed from environmental pathogens is critical for healing and preventing secondary infection.

Choice B rationale

. Air exposure causes desiccation of the wound bed, which leads to cell death and delayed healing. Dry environments promote eschar formation, increasing the risk of scarring. Maintaining a moist interface is the gold standard for promoting rapid dermal repair.

Choice C rationale

. Dry gauze adheres to the wound exudate and causes significant tissue damage during removal. Tight application can also impair local capillary circulation, leading to ischemia. Dressings should be applied loosely enough to ensure adequate perfusion to the healing tissue.

Choice D rationale

. Intact blisters serve as a biological dressing, protecting the underlying dermis from infection. Removing them prematurely exposes the wound bed unnecessarily to the external environment. They should only be debrided if they are large enough to impede joint movement.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

This scenario requires evaluating medical orders against a client's specific allergy profile to morphine, iodine, and codeine. Knowledge of hypersensitivity reactions to intravenous contrast media and the safe selection of analgesics is necessary to ensure patient safety and prevent potentially fatal allergic responses.

Choice A rationale

Iodine is a primary component of many intravenous contrast agents used in imaging. The client's documented iodine allergy necessitates questioning this order to avoid life-threatening systemic reactions, such as angioedema or airway obstruction, typically associated with radiopaque medium exposure.

Choice B rationale

Therapeutic lifestyle changes, including dietary modifications, are foundational in stroke prevention. Reducing dietary fats and cholesterol helps mitigate cardiovascular risk factors, supporting the long-term management of transient ischemic attacks without conflicting with the client's specific known drug allergies.

Choice C rationale

Protocol-based vital sign monitoring ensures the early detection of neurological or hemodynamic instability. This order is a standard of care for any patient presenting with cerebrovascular symptoms and carries no risk related to the client's iodine or opioid sensitivities.

Choice D rationale

Acetaminophen belongs to the para-aminophenol derivative class of medications. It does not possess the structural components of phenanthrene alkaloids like morphine or codeine, making it a safe alternative for treating mild to moderate pain in opioid-allergic individuals..

A. Movement of the trachea toward the unaffected side. B. Eyelets are not visible. C. Crepitus in the area above and surrounding the insertion site. D. Bubbling of the water in the water seal chamber with exhalation.

Correct Answer is A

Explanation

Chest tube management for pneumothorax involves monitoring for clinical complications and system patency. This scenario requires applying knowledge of respiratory emergencies, specifically recognizing signs of tension pneumothorax, which is a life threatening complication characterized by shifting of thoracic structures.

Choice A rationale

Tracheal deviation toward the unaffected side signifies a tension pneumothorax. This occurs when intrapleural pressure increases significantly, causing a mediastinal shift that compresses the heart and opposite lung, requiring immediate needle decompression or chest tube adjustment by providers.

Choice B rationale

Eyelets are the drainage holes at the end of the chest tube. If they are not visible, it indicates the tube is correctly positioned within the pleural space. Visible eyelets would suggest the tube has partially dislodged.

Choice C rationale

Crepitus, or subcutaneous emphysema, is a common finding where air leaks into subcutaneous tissues around the insertion site. While it should be monitored and documented, it generally does not require emergency provider notification unless it rapidly expands.

Choice D rationale

Intermittent bubbling in the water seal chamber during exhalation or coughing is expected in a patient with a pneumothorax. It indicates that air is successfully being evacuated from the pleural space into the drainage system.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A client presents with superficial burns and multiple intact blisters on the forearm. During dressing change, several blisters rupture and the underlying skin is exposed. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client being admitted with a transient ischemic attack reporting a headache is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse querry

Correct Answer is A

Explanation

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Correct Answer is A

Explanation

A client presents to the emergency department in severe pain and reports that a pot of boiling water accidentally spilled on his lower legs. The assessment reveals soft and dry eschar, mottled red skin, and moderately edematous feet. Which depth of burn should the nurse document?

The client being admitted with a transient ischemic attack (TIA) is reporting a headache. The client is allergic to morphine, iodine, and codeine. Which healthcare provider order should the nurse ask to clarify?

A nurse is caring for a client who has pericarditis and reports feeling a new onset of palpitations and shortness of breath. Which of the following assessments should indicate to the nurse that the client may have developed atrial fibrillation?

A client with an ischemic stroke has right-sided weakness and slurred speech. Which complication should the nurse prioritize monitoring for in the first 24 hours?

The trauma intensive care nurse suspects a client with a C6 fracture has developed neurogenic shock. Which findings support the nurse's suspicion?

The nurse is assessing a client with a brain tumor who is prescribed dexamethasone. Which assessment change creates the highest priority situation?

The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?

A client presents with superficial burns and multiple intact blisters on the forearm.
During dressing change, several blisters rupture and the underlying skin is exposed. Which action should the nurse take?