A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?
Skin is red, blanches, and weeps
Skin has a leathery and dry
Skin is waxy in appearance
Skin is intact, dry, and red in color
The Correct Answer is A
A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.
B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.
C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.
D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Oxygen saturation 93%:
While this is slightly below normal, it is not a definitive or specific indicator of fluid overload.
B. Distended neck veins:
Jugular vein distention is a classic sign of fluid overload and increased central venous pressure.
C. The client has gained 1 pound since yesterday:
A 1-pound weight gain could be due to fluid retention, but it's not significant enough on its own to confirm fluid overload.
D. Return of skin to previous position when the client's shin is palpated:
This indicates normal skin turgor and does not suggest fluid overload; instead, it rules out dehydration.
Correct Answer is A
Explanation
A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.
B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.
C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.
D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.
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