A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?

Erythema

Eschar

Blistering

Absence of pain

Answer and Explanation

The Correct Answer is A

Choice A rationale: Erythema (redness) is the first indication of a superficial burn injury. Superficial burns, also known as first-degree burns, involve only the outer layer of the skin and are characterized by redness without blistering.
Choice B rationale: Eschar is associated with deeper burns and is not the first indication of a superficial burn.
Choice C rationale: Blistering is associated with partial-thickness burns (second-degree burns) and does not occur in superficial burns.
Choice D rationale: Pain is typically present in superficial burns, and the absence of pain is not a characteristic of superficial burns.

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Correct Answer is B

Explanation

Choice A rationale: Rubbing the affected area may exacerbate pruritus and potentially spread scabies.
Choice B rationale: Providing mittens can prevent the client from scratching the affected areas, promoting healing and preventing the spread of scabies.
Choice C rationale: Hot water can worsen itching and should be avoided in scabies management.
Choice D rationale: The application of scabicide should follow the prescribed treatment plan, and additional application without guidance may lead to overuse and potential adverse effects.

A. Swab the wound bed with a sterile cotton-tipped swab B. Cleanse the area around the wound with sterile saline. C. Don sterile gloves D. Place the collection tube in a specimen bag.

Correct Answer is C

Explanation

- A: Swabbing the wound bed is an essential step in obtaining a wound culture, but it is not the first action that should be taken. This step is performed after the wound has been cleansed to ensure that the sample is not contaminated with debris or bacteria from the surrounding skin.
- B: Cleansing the area around the wound with sterile saline is the correct first step. This action helps to remove any contaminants or debris from the wound surface, ensuring that the culture obtained is from the wound itself and not from the surrounding skin, which could lead to inaccurate results.
- C: Donning sterile gloves is a crucial step to maintain sterility during the procedure. However, it is not the first action because the nurse must first cleanse the wound area to prevent contamination of the culture specimen.
- D: Placing the collection tube in a specimen bag is done after obtaining the wound culture to transport the specimen to the laboratory. This is one of the final steps in the process, not the first.

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A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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