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 : A blood pressure of 138/76 mm Hg is within the higher range of normal and is not typically considered an adverse effect of metoprolol, which is used to lower blood pressure.

Choice B reason : A temperature of 36.3°C (97.3°F) is within the normal range and is not an adverse effect of metoprolol.

Choice C reason : A heart rate of 48/min is considered bradycardia and can be an adverse effect of metoprolol, which is a beta-blocker that can slow down the heart rate.

Choice D reason : A respiratory rate of 10/min is on the lower end of the normal range but is not a typical adverse effect of metoprolol. However, if the patient shows signs of respiratory distress, it should be addressed.

A. Aspirate the catheter to check for a brisk blood return. B. Use sterile technique for the procedure. C. Cleanse the insertion site with hydrogen peroxide. D. Flush the TPN port with 20 mL of 0.9% sodium chloride.

Correct Answer is B

Explanation

Choice A reason: Aspirating the catheter to check for a brisk blood return is not typically recommended as a routine action when replacing the dressing of a PICC line used for TPN. This action is performed to verify patency and placement of the catheter, but it is not directly related to the dressing change procedure.

Choice B reason: Using sterile technique for the procedure is essential when replacing the dressing of a PICC line. Maintaining sterility is crucial to prevent infection, as the PICC line provides direct access to the central venous system. The nurse should use sterile gloves and follow aseptic protocols to minimize the risk of introducing pathogens at the catheter insertion site.

Choice C reason: Cleansing the insertion site with hydrogen peroxide is not recommended for PICC line care. Hydrogen peroxide can be damaging to the tissue and may delay healing. Instead, a chlorhexidine-based antiseptic is typically used to clean the skin around the insertion site during dressing changes to reduce microbial flora and prevent infection.

Choice D reason: Flushing the TPN port with 20 mL of 0.9% sodium chloride is a practice used to maintain catheter patency, but it is not part of the dressing change procedure. Flushing is usually done before and after administering medication or nutrition, not specifically during a dressing change.

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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

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