The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Deep partial-thickness.

Full-thickness.

Superficial partial-thickness.

Deep full-thickness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.

Choice B reason:

The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.

Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.

Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.

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Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because taking deep breaths followed by coughing helps produce a sputum sample from the lungs, which is necessary for accurate diagnostic testing.

Choice B reason: Restricting fluids before expectorating the sputum specimen is not necessary and may make it more difficult to produce a sample.

Choice C reason: Sputum specimens are best collected in the morning when secretions have accumulated overnight.

Choice D reason: Mouth care should be performed prior to sputum collection to reduce contamination from oral bacteria.

A. Preoperative chest x-ray report is not available. B. Surgical consent form is not signed. C. Preoperative serum potassium level is 2.8 mEq/L (2.8 mmol/L). D. Client's pulse oximeter reading is 96%.

Correct Answer is C

Explanation

Choice A reason: While the chest x-ray report is important, it is not as immediately critical as a low potassium level.

Choice B reason: The surgical consent form is important but can be addressed quickly before surgery.

Choice C reason:

The correct answer is c) because a preoperative serum potassium level of 2.8 mEq/L is dangerously low and requires immediate correction to avoid cardiac complications during surgery.

Choice D reason: A pulse oximeter reading of 96% is within normal limits and does not require immediate action.

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The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client how to collect a sputum specimen. Which steps should the nurse instruct the client to follow when collecting a sputum sample?

Correct Answer is A

Explanation

Two hours before a client's scheduled surgery, the nurse is completing the preoperative checklist. Which information requires immediate action by the nurse?

Correct Answer is C

Explanation

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The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

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