A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?
Erythema
Eschar
Blistering
Absence of pain
The Correct Answer is A
Choice A rationale: Erythema (redness) is the first indication of a superficial burn injury. Superficial burns, also known as first-degree burns, involve only the outer layer of the skin and are characterized by redness without blistering.
Choice B rationale: Eschar is associated with deeper burns and is not the first indication of a superficial burn.
Choice C rationale: Blistering is associated with partial-thickness burns (second-degree burns) and does not occur in superficial burns.
Choice D rationale: Pain is typically present in superficial burns, and the absence of pain is not a characteristic of superficial burns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: individuals with extensive burn wounds are highly likely to develop metabolic acidosis and not metabolic alkalosis due to the increased risk of tissue hypoxia, increased lactic acid levels, and renal failure.
Choice B rationale: low hemoglobin is not an expected finding in individuals with extensive burn wounds but instead increased hemoglobin levels are expected due to hemoconcentration resulting from excessive fluid loss.
Choice C rationale: A patient with extensive burn wounds is expected to have hypovolemia and not hypervolemia due to increased fluid loss from the burned tissues and increased capillary permeability.
Choice D rationale: hyperkalemia is a common finding in individuals with extensive burn wounds due to massive cell destruction which releases potassium from the intracellular compartment to the extracellular compartment.
Correct Answer is B
Explanation
Choice A rationale: this is a type of non-adherent dressing that can be used for wounds with minimal exudates hence this is not suitable for wounds with significant exudate since it causes maceration and leakage.
Choice B rationale: this is an absorbent dressing that can be used in wounds with moderate-significant exudate since it moistens the wound environment while facilitating autolytic debridement by forming a gel in contact with the exudate.
Choice C rationale: this is a type of hydrating dressing containing water or glycerin-based gel that is suitable for use in wounds with minimal exudate.
Choice D rationale: this is a type of occlusive dressing suitable for wounds with minimal-moderate exudates. It is unsuitable for wounds with significant exudate since it can result in maceration and leakage.
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