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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.
B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.
C. Muscle weakness:
Can occur but is less urgent than cardiac effects.
D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.
Correct Answer is D
Explanation
Formula: 4 mL × Body weight (kg) × %TBSA
4 × 100 × 40 = 16,000 mL total in 24 hours
Half (8,000 mL) is given in the first 8 hours
Answer- 8000ml
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