A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Minimal edema in the affected extremities

Temperature of 39.1 C (102.4 F)

Pain at the burn sites

urine output of 30 ml/hr

Answer and Explanation

The Correct Answer is B

A. Minimal edema in the affected extremities:
Expected after 72 hours as inflammation begins to subside.

B. Temperature of 39.1°C (102.4°F):
Elevated temperature may indicate infection or systemic inflammation and should be reported.

C. Pain at the burn sites:
Pain is expected, especially in partial-thickness burns where nerve endings are exposed.

D. Urine output of 30 mL/hr:
While on the lower end of normal, this is still acceptable for an adult (minimum: 30 mL/hr).

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Correct Answer is ["B","C","D","E"]

Explanation

A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.

B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.

C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.

D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.

E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.

A. Allergic reaction in patients with sulfa allergies B. Increased risk of infection C. Delayed wound healing D. Improved wound healing

Correct Answer is A

Explanation

A. Allergic reaction in patients with sulfa allergies:
Silver sulfadiazine contains a sulfa compound and is contraindicated in patients with sulfonamide allergies.

B. Increased risk of infection:
Silver sulfadiazine is antimicrobial, and reduces infection risk, not increases it.

C. Delayed wound healing:
Some studies suggest it may delay epithelialization, but this is not the most common or concerning reaction.

D. Improved wound healing:
It helps prevent infection, but does not significantly accelerate healing. The focus is on infection control, not wound closure.

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A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Priority nursing diagnoses for burns include: (Select All That Apply)

Correct Answer is ["B","C","D","E"]

Explanation

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Correct Answer is A

Explanation

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