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A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?

Admission Notes: 36 y/o female with bilateral leg burns. NKFDA. Health history of asthma and seasonal allergies. Wound Assessment: Bilateral leg burns present with a white and leather Like appearance. No blisters or bleeding present. Patient rates pain 2/10 on a scale of 0 to 1 0

Full thickness

Superficial

Partial-thickness superficial

Partial-thickness deep

Answer and Explanation

The Correct Answer is A

A. Full thickness:

Full-thickness burns involve damage to the entire thickness of the skin, including the epidermis and dermis. They often result in a white, charred, or leather-like appearance and are typically painless due to nerve damage. In the context of the patient's data, the description of "bilateral leg burns present with a white and leather-like appearance" indicates that the burns have penetrated deeply into the skin, suggesting full-thickness burns. The absence of blisters or bleeding is also consistent with full-thickness burns, as these burns often destroy the structures that would form blisters.

B. Superficial:

Superficial burns, also known as first-degree burns, only affect the outer layer of the skin (epidermis).They are characterized by redness, pain, and swelling but do not typically result in blisters or significant skin damage. The patient's description of "white and leather-like appearance" and the absence of blisters or bleeding are not indicative of superficial burns. Therefore, superficial burns are not an appropriate categorization based on the provided data.

C. Partial-thickness superficial:

Partial-thickness superficial burns, also known as second-degree superficial burns, affect the epidermis and part of the dermis. They are characterized by redness, blister formation, and pain. However, the description of "white and leather-like appearance" does not align with partial-thickness superficial burns, as these burns typically do not result in a white or charred appearance. Additionally, the absence of blisters or bleeding is not consistent with partial-thickness superficial burns.

D. Partial-thickness deep:

Partial-thickness deep burns, also known as second-degree deep burns, extend deeper into the dermis compared to partial-thickness superficial burns but do not penetrate through the entire dermis. They are characterized by redness, blister formation, and moderate to severe pain. The absence of blisters or bleeding and the description of "white and leather-like appearance" are more indicative of full-thickness burns rather than partial-thickness deep burns.

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. "Bake or grill the meat rather than frying it."

This statement is more related to reducing fat intake rather than managing sodium levels. While reducing fried foods can be beneficial for overall health, it doesn't directly address the issue of sodium intake, which is crucial in managing hypernatremia.

B. “Check your radial pulse twice a day.”

Checking the radial pulse is a method used to monitor heart rate and rhythm. It is not directly related to managing sodium levels or hypernatremia. Although monitoring vital signs is important in general health care, it is not specific to addressing mild hypernatremia.

C. "Read food labels to determine sodium content."

This statement is the correct choice. Managing sodium intake is a key component in managing hypernatremia. Reading food labels helps patients identify high-sodium foods and make choices that are lower in sodium content, which can be crucial in preventing or managing mild hypernatremia.

D. “Weigh yourself every morning and every night."

While regular weight monitoring can be important for certain health conditions, it is not directly related to managing mild hypernatremia. Weight changes may occur with fluid retention or loss, but monitoring sodium intake and hydration status is more directly relevant to managing hypernatremia.

A. The transfusion will begin after the administration of 650 mg of acetaminophen {Tylenol). B. The blood will be held, and the health care provider will be notified C. The transfusion will begin after the administration of an antihistamine D. The transfusion will begin as prescribed

Correct Answer is A

Explanation

A. The transfusion will begin after the administration of 650 mg of acetaminophen (Tylenol).

This option suggests that the nurse would administer acetaminophen to lower the client's temperature and then proceed with the blood transfusion. While acetaminophen can be used to reduce fever, the decision to administer medication should be made by the healthcare provider after assessing the client's overall condition and determining the cause of the fever. Administering medication without proper evaluation and orders from the healthcare provider is not appropriate.

B. The blood will be held, and the health care provider will be notified.

This option is the correct choice. When a client has an elevated temperature before a blood transfusion, it is standard practice to hold the transfusion and notify the healthcare provider. An elevated temperature could indicate an underlying infection or another condition that needs to be evaluated before proceeding with the transfusion to ensure the client's safety.

C. The transfusion will begin after the administration of an antihistamine.

Administering an antihistamine would not be the appropriate action in response to an elevated temperature before a blood transfusion. Antihistamines are typically used to treat allergic reactions, not fevers. Holding the transfusion and notifying the healthcare provider to assess the situation would be the correct course of action.

D. The transfusion will begin as prescribed.

This option is not appropriate because starting the transfusion without addressing the elevated temperature could pose risks to the client's health. Elevated temperatures may indicate an underlying infection or other conditions that need to be evaluated before proceeding with the transfusion. Holding the transfusion and seeking further guidance from the healthcare provider is the recommended action in this scenario.

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A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse teaches a patient who is at risk for mild hypernatremia. Which statement does the nurse include in this patient's teaching?

Correct Answer is C

Explanation

The nurse takes a client's temperature before giving a blood transfusion. The temperature is 100 F orally. The nurse reports the finding to the registered nurse (RN) and anticipates that which action will take place?

Correct Answer is A

Explanation

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