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

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.

B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.

C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.

D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.

A. Cool and clammy skin B. Purulent drainage from the burn site C. Muscle weakness D. Irregular heart rhythm

Correct Answer is D

Explanation

A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.

B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.

C. Muscle weakness:
Can occur but is less urgent than cardiac effects.

D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.

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A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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