A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?

Epithelialization at the site

Severe pain at the site

Edema at the site

Blistering at the site

Answer and Explanation

The Correct Answer is C

Choice A reason: Epithelialization at the site of a major full-thickness burn would not be expected 12 hours post-injury. Epithelialization is a later stage of wound healing where new skin cells form and cover the wound. In full-thickness burns, this process is significantly delayed and typically requires skin grafting for wound closure.

Choice B reason: Severe pain is not typically associated with full-thickness burns due to the destruction of nerve endings in the skin. However, there may be severe pain in the surrounding areas that have sustained less severe burns.

Choice C reason: Edema is a common and expected finding at the site of a major full-thickness burn 12 hours post-injury. The inflammatory response to the burn injury leads to increased vascular permeability and fluid shift from the intravascular to the interstitial space, resulting in edema.

Choice D reason: Blistering is characteristic of partial-thickness burns (second-degree burns) but not full-thickness burns (third-degree burns). In full-thickness burns, the skin is destroyed to the point where blisters do not form.

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Correct Answer is C

Explanation

Choice A reason: Irrigating the affected eye from the inner corner toward the outer corner is the recommended method for ocular irrigation. This technique helps to flush out the chemical agent without risking further contamination to the other eye or nasal passages.

Choice B reason: Positioning the client sitting up with their head turned toward the right side is appropriate when irrigating the left eye. This position allows gravity to assist in the flow of the irrigation solution away from the unaffected eye, reducing the risk of cross-contamination.

Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is a critical step in ocular irrigation after a chemical splash. It is used to measure the pH of the ocular surface to ensure that the pH has normalized to a range between 7.0 and 7.2 after irrigation, indicating that the chemical has been adequately flushed out.

Choice D reason: Using sterile water for ocular irrigation is not recommended because it can cause osmotic imbalances and damage to the corneal cells. Instead, normal saline or balanced salt solutions are preferred as they are isotonic and more compatible with the physiological environment of the eye.

A. "Your provider wouldn't prescribe this medication if it weren't necessary." B. "If you don't take this medication, you will feel worse." C. "Most clients feel better after taking the antibiotic." D. "I will tell your provider that you do not want to take this medication."

Correct Answer is A

Explanation

Choice A reason: "Your provider wouldn't prescribe this medication if it weren't necessary." This response acknowledges the client's concerns while also reinforcing the importance of the medication as part of their treatment plan.

Choice B reason: "If you don't take this medication, you will feel worse." This response may come across as threatening and may not effectively address the client's concerns or foster a trusting relationship.

Choice C reason: "Most clients feel better after taking the antibiotic." While this may be true, it does not directly address the client's individual concerns about medication necessity.

Choice D reason: "I will tell your provider that you do not want to take this medication." This response does not engage with the client's concerns and may make the client feel unheard.

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A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to assist with an ocular irrigation for a client who had a chemical splash to the left eye. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing to administer heparin subcutaneously to a client. Which of the following is an appropriate action by the nurse?

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