A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

Skin is red, blanches, and weeps

Skin has a leathery and dry

Skin is waxy in appearance

Skin is intact, dry, and red in color

Answer and Explanation

The Correct Answer is A

A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.

B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.

C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.

D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.

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Correct Answer is C

Explanation

A. Orange juice: Does not affect cyclosporine metabolism.

B. Bananas: No known interaction with cyclosporine.

C. Grapefruit juice: Inhibits CYP3A4 enzyme in the liver, which increases cyclosporine levels, leading to toxicity.

D. Smoked salmon: May contain sodium but does not interact with cyclosporine metabolism.

A. Encourage the client to cough and auscultate the lungs again. B. Document the change and continue to monitor the client's respiratory rate. C. Notify the health care provider and prepare for endotracheal intubation. D. Reposition the client in high-Fowler's position and reassess breath sounds.

Correct Answer is C

Explanation

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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