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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
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.
Correct Answer is C
Explanation
Choice A rationale: tachycardia is an expected finding in burns patients due to the increase in metabolic rate and fluid loss.
Choice B rationale: a urine output of 25 ml/hr is too low for an individual with burns hence the need for adequate fluid resuscitation. However, this is not a priority sign compared with the difficulty in breathing.
Choice C rationale: difficulty in swallowing is an indicator of airway edema which may compromise the patients breathing and oxygenation which may result in death. Therefore, the healthcare provider should be notified to assess the need for intubation.
Choice D rationale: Pain of 6 on a scale of 0 to 10 is moderate and is expected due to burns and can be managed with analgesics and nonpharmacological interventions.
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