A nurse is caring for a client with an electrical burn.

The client states that since the wound on the skin is small, the burn must not be too bad.

Which of the following is the best response by the nurse?

Electrical burns usually cause much more skin damage than what can be seen on your skin.

Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.

Electrical burns commonly cause reddened/purplish skin without blistering.

Electrical burns typically are minor.

Answer and Explanation

The Correct Answer is B

Choice A rationale
While it’s true that electrical burns can cause more skin damage than what can be seen on the skin, this statement does not fully address the client’s misconception about the severity of their burn.
Choice B rationale
This is the best response because it directly addresses the client’s misconception and provides accurate information. Electrical burns can indeed have small amounts of skin damage but cause more extensive damage beneath the skin. This is because the electrical current can pass through the body and damage internal tissues and organs, even if the visible wound on the skin is small.
Choice C rationale
While electrical burns can cause reddened or purplish skin, they do not typically cause blistering. Furthermore, this statement does not address the client’s misconception about the severity of their burn.
Choice D rationale
This statement is incorrect. Electrical burns are not typically minor. They can cause serious internal injuries and complications, even if the visible wound on the skin is small.

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Correct Answer is C

Explanation

Choice A rationale
Areas around pins being dry is a normal finding and does not need to be reported.
Choice B rationale
Crusts around pins are also a normal finding as they are usually dried exudate and do not indicate an infection.
Choice C rationale
Purulent drainage around pins is a sign of infection. This should be reported to the unit care coordinator immediately as it may require antibiotic treatment.
Choice D rationale
Absence of pain at the site is a normal finding and does not need to be reported.

A. Attached to the foot of the bed. B. Below the level of the patient’s chest. C. Along the side of the patient’s knee. D. At the level of the patient’s clavicle.

Correct Answer is B

Explanation

Choice A rationale
Attaching the chest tube system to the foot of the bed is not recommended. This position could potentially cause the system to tip over or become disconnected, which could lead to complications such as pneumothorax or hemothorax.
Choice B rationale
The chest tube system should be placed below the level of the patient’s chest. This allows for gravity-assisted drainage of air and fluid from the thoracic cavity, which is crucial for the patient’s recovery. The system works on a water seal that prevents air or fluid from entering the pleural space. Placing the system below the chest level ensures that the water seal is maintained, preventing backflow of fluid or air into the pleural space.
Choice C rationale
Placing the system along the side of the patient’s knee is not appropriate. This position does not facilitate effective drainage of air and fluid from the thoracic cavity. It could also lead to discomfort and potential dislodgement of the system.
Choice D rationale
Placing the system at the level of the patient’s clavicle is not recommended. This position is too high and could disrupt the water seal, leading to ineffective drainage and potential complications.

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A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

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A nurse is caring for a client with an electrical burn.

The client states that since the wound on the skin is small, the burn must not be too bad.

Which of the following is the best response by the nurse?