A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

The client produces black colored sputum.

The client has decreased sensation over the burn areas.

The client has edema at the burn site.

The client has large blistered areas over his chest.

Answer and Explanation

The Correct Answer is A

A. The client produces black colored sputum.
Black sputum indicates inhalation injury, which can compromise the airway-this is a life-threatening emergency and takes priority.

B. The client has decreased sensation over the burn areas.
This is expected in deep partial- or full-thickness burns but is not immediately life-threatening.

C. The client has edema at the burn site.
Edema is common after burns due to capillary leakage and inflammation.

D. The client has large blistered areas over his chest.
While concerning, this is not a higher priority than potential airway compromise.

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Correct Answer is C

Explanation

A. Bright-red, moist lesions:
This describes superficial partial-thickness burns, not full-thickness burns.

B. Blackened, painful lesions:
Full-thickness burns may appear black (eschar), but they are typically painless due to nerve destruction.

C. Snowy white, painless lesions:
Full-thickness burns can be white, leathery, or charred and are often painless due to complete nerve damage.

D. Blistered, pinkish-white, painful lesions:
These are characteristic of deep partial-thickness burns, which retain some nerve sensation.

A. A client who has swelling and tenderness around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling and tenderness around the wound:
These are classic signs of infection, indicating inflammation and possible bacterial invasion.

B. Urticaria and itching around the wound:
These are signs of an allergic reaction, not infection.

C. Serosanguineous drainage from the wound:
This is normal wound drainage, especially in early healing.

D. Brown crusting over the wound:
This may indicate scab formation or dried exudate, not necessarily infection.

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A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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