A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

Full-Thickness (Third-Degree)

Superficial (First-Degree)

Deep Full-Thickness (Fourth-Degree)

Partial-Thickness (Second-Degree)

Answer and Explanation

The Correct Answer is A

A. Full-Thickness (Third-Degree). A third-degree (full-thickness) burn destroys both the epidermis and dermis, leaving the skin dry, white, or charred. Due to nerve damage, the patient does not experience pain in the affected area.

B. Superficial (First-Degree). A first-degree burn affects only the epidermis and presents with redness, mild swelling, and pain. The skin remains intact, unlike the description provided.

C. Deep Full-Thickness (Fourth-Degree). A fourth-degree burn extends beyond the skin into muscle, bone, or fat. The description does not indicate such deep involvement.

D. Partial-Thickness (Second-Degree). A second-degree burn involves the epidermis and part of the dermis, causing blistering, redness, and pain. This is not consistent with the described dry, white, and painless presentation.

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Correct Answer is B

Explanation

A. "Skeletal traction has less risk for infection than skin traction." Skeletal traction involves pins and has a higher infection risk than skin traction.

B. "Skeletal traction is more appropriate than skin traction for reducing a fracture." Skeletal traction provides stronger and more stable force, making it more appropriate for fracture reduction.

C. "Clients with skin traction have more discomfort than those with skeletal traction." Skeletal traction is usually more painful due to pins inserted into the bone.

D. "Skin traction is primarily used for long-term stabilization of fractures." Skin traction is typically used short-term before surgery.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Pressure Ulcer D. Stage II Pressure Ulcer

Correct Answer is C

Explanation

A. Deep Tissue Injury. Deep tissue injuries appear as intact or discolored skin (purple or maroon) due to underlying soft tissue damage. This wound is already open with slough, so it does not fit this category.

B. Stage III Pressure Ulcer. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue, but the wound depth must be assessable. Since the slough covers the wound, the depth cannot be determined.

C. Unstageable Pressure Ulcer. An unstageable pressure ulcer is one where the base of the wound is covered with slough or eschar, preventing assessment of the full depth of tissue damage. Until the slough is removed, the stage cannot be determined.

D. Stage II Pressure Ulcer. A Stage II ulcer has partial-thickness skin loss with exposed dermis, often appearing as an open blister or shallow wound. The presence of thick slough suggests deeper involvement, making this an incorrect classification.

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A nurse is assessing a patient who has sustained a burn injury. The affected area is dry, white, and charred, with no pain present. Based on the classification of burns, the nurse understands this burn is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is discussing the differences between skeletal and skin traction with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding?

Correct Answer is B

Explanation

A nurse is assessing a patient with a pressure ulcer on the heel (as shown in the image). The wound is covered with thick yellow slough, making it difficult to determine the depth of tissue damage. How should the nurse classify this wound?

Correct Answer is C

Explanation

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