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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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Correct Answer is D

Explanation

A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.

B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.

C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.

D. Decontamination of the client

When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.

A. Metabolic acidosis B. Respiratory acidosis C. Respiratory alkalosis D. Metabolic alkalosis

Correct Answer is B

Explanation

A. Metabolic acidosis:

Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) due to an excess of acids in the body or a loss of bicarbonate. However, in the given ABG values, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not align with metabolic acidosis. Therefore, metabolic acidosis is not the correct interpretation in this case.

B. Respiratory acidosis:

Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 in the blood and a decrease in pH. In the ABG values provided, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis as the primary disturbance. This interpretation is supported by the elevated PaCO2 and the low pH, making it the correct choice based on the given data.

C. Respiratory alkalosis:

Respiratory alkalosis results from hyperventilation, leading to excessive elimination of CO2 and a decrease in PaCO2 levels. However, in the ABG values presented, the PaCO2 is elevated (68 mm Hg), which contradicts the expected decrease seen in respiratory alkalosis. Therefore, respiratory alkalosis is not the correct interpretation of the ABG values in this case.

D. Metabolic alkalosis:

Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L) due to excessive loss of acids or an increase in bicarbonate levels. However, in the ABG values provided, the pH is low (7.22), and the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic alkalosis. Therefore, metabolic alkalosis is not the correct interpretation based on the given data.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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