A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

Full-Thickness (Third-Degree)

Superficial (First-Degree)

Deep Full-Thickness (Fourth-Degree)

Partial-Thickness (Second-Degree)

Answer and Explanation

The Correct Answer is A

A. Full-Thickness (Third-Degree). A third-degree (full-thickness) burn destroys both the epidermis and dermis, leaving the skin dry, white, or charred. Due to nerve damage, the patient does not experience pain in the affected area.

B. Superficial (First-Degree). A first-degree burn affects only the epidermis and presents with redness, mild swelling, and pain. The skin remains intact, unlike the description provided.

C. Deep Full-Thickness (Fourth-Degree). A fourth-degree burn extends beyond the skin into muscle, bone, or fat. The description does not indicate such deep involvement.

D. Partial-Thickness (Second-Degree). A second-degree burn involves the epidermis and part of the dermis, causing blistering, redness, and pain. This is not consistent with the described dry, white, and painless presentation.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

A. 50%. This overestimates the TBSA based on the Rule of Nines.

B. 40.5%. Using the Rule of Nines:

Anterior right arm = 4.5%
Anterior trunk = 18%
Anterior right leg = 9%
Anterior left leg = 9%
Total TBSA = 4.5% + 18% + 9% + 9% = 40.5%

C. 20.5%. This underestimates the TBSA affected by burns.

D. 30.5%. This does not accurately reflect the total body surface area affected.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Pressure Ulcer D. Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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 nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 40-year-old male patient presents with partial-thickness burns affecting the anterior right arm, anterior trunk, and anterior right leg and anterior left leg. Based on the Rule of Nines, what percentage of the total body surface area (TBSA) is burned?

Correct Answer is B

Explanation

A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Correct Answer is C

Explanation

A nurse is assessing a client who reports burning, stabbing pain on their right thorax. The nurse notes the presence of a unilateral vesicular rash following a dermatome. Based on these findings, which of the following is the most likely diagnosis?

Which of the following actions should the nurse take immediately to prevent complications?

A nurse is caring for a client who is scheduled for an arthroplasty. The nurse asks client to state if he understands the procedure that is being performed. Which of the following statements by the client indicates an understanding of the procedure?

A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

A nurse is caring for a patient post-total hip arthroplasty. Which of the following findings requires immediate intervention?

A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?