A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.
Muscle layers
Epidermal layers
Dermal layers
Subcutaneous layers
Bone and ligaments
Correct Answer : A,B,C,D
A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.
B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.
C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.
D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.
E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.
B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.
C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.
D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.
Correct Answer is A
Explanation
A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.
B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.
C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.
D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.
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