A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Soles of the feet

Ear lobes

Oral mucosa

Conjunctivae

Answer and Explanation

The Correct Answer is C

This is because central cyanosis reflects a decrease in arterial oxygen saturation and is best seen in areas where blood vessels are close to the surface, such as the oral mucosa, tongue, and lips. Peripheral cyanosis, which may be caused by vasoconstriction or poor circulation, can be seen in the soles of the feet, ear lobes, and nail beds, but it does not necessarily indicate hypoxemia.

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Correct Answer is D

Explanation

This is because according to the rule of nines, each arm accounts for 9 percent and each leg accounts for 18 percent of the TBSA. Therefore, burns on both arms and both legs equal (9+9+18+18) =54%.

A. "This procedure involves placing the client into a shower and removing the dead tissue." B. "Dead tissue will be non-surgically removed." C. "Large incisions will be made in the eschar to improve circulation." D. "A piece of healthy skin will be removed from an unburned area and grafted over the burned area."

Correct Answer is C

Explanation

An escharotomy is a surgical procedure that involves making incisions in the eschar, which is the hard, blackened tissue that forms over a severe burn wound. The eschar can restrict blood flow and cause compartment syndrome, which can lead to tissue necrosis and nerve damage. By cutting through the eschar, the pressure is relieved and circulation is restored. This procedure does not involve removing the dead tissue, which is done by debridement or hydrotherapy. A skin graft is a different procedure that involves transplanting healthy skin from another site to cover a burn wound.

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A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is D

Explanation

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Correct Answer is C

Explanation

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