The nurse is caring for a patient with a burn that is severely swollen, and the wound bed appears brown and yellow. The patient reports no pain. How should the nurse classify the depth of this burn?
Superficial partial-thickness.
Full-thickness.
Deep partial-thickness.
Deep full-thickness.
The Correct Answer is B
Choice A rationale
A superficial partial-thickness burn involves the destruction of the epidermis and possibly a portion of the dermis. The description provided does not match this type of burn.
Choice B rationale
A full-thickness burn involves total destruction of the epidermis and dermis, and in some cases, the underlying tissue, muscle, and bone. The description of the burn as severely swollen, with a wound bed that appears brown and yellow, and the patient reporting no pain, is consistent with a full-thickness burn.
Choice C rationale
A deep partial-thickness burn involves the destruction of the epidermis and upper layers of the dermis and injury to the deeper portions of the dermis. The description provided does not match this type of burn.
Choice D rationale
Deep full-thickness burns are a more severe form of full-thickness burns that extend beyond the dermis into deeper tissues. The description provided does not match this type of burn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Rubbing painful areas gently until the pain subsides is not typically recommended for managing pain in Raynaud’s disease. This could potentially cause more harm than good19.
Choice B rationale
Wearing gloves when handling cold items can help guard against painful spasms in Raynaud’s disease. Cold temperatures can trigger Raynaud’s attacks, so protecting the hands from cold is a key part of managing the condition19.
Choice C rationale
The need for return appointments for IV pain medication is not typically a primary component of pain management in Raynaud’s disease. Pain in Raynaud’s disease is usually managed through lifestyle modifications and medications19.
Choice D rationale
While enrolling in a pain clinic can provide pain relief alternatives, it’s not the first line of management for pain in Raynaud’s disease. The primary management strategies include avoiding cold exposure and using medications to improve blood flow19.
Correct Answer is C
Explanation
Choice A rationale
Huff coughing is a method that forces mucus up your throat by breathing it in, holding it, and actively exhaling. It’s different from a typical cough and more effective in clearing mucus from the lungs. Pursed-lip breathing, which the patient is doing, is not part of the huff coughing technique.
Choice B rationale
Taking several shallow breaths before the next exhalation is not part of the huff coughing technique. The technique involves taking a slow and deep breath until your lungs are about 75% full, holding your breath for two to three seconds, and then exhaling slowly but strongly.
Choice C rationale
Instructing the patient to inhale deeply and then quickly and forcefully exhale 2 to 3 times is the correct method for huff coughing. This technique helps to move mucus from the smaller airways to the larger ones, making it easier to cough up and out.
Choice D rationale
Positioning the patient in the semi-Fowler’s position and applying oxygen is not part of the huff coughing technique. While oxygen therapy can be beneficial for patients with COPD, it does not directly aid in the huff coughing technique.
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