The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Deep partial-thickness.

Full-thickness.

Superficial partial-thickness.

Deep full-thickness.

Answer and Explanation

The Correct Answer is B

Choice A reason: Deep partial-thickness burns are characterized by blisters and significant pain.

Choice B reason:

The correct answer is b) because full-thickness burns involve all layers of the skin and can extend into underlying tissues. They often appear brown or yellow and are usually painless due to nerve damage.

Choice C reason: Superficial partial-thickness burns affect the epidermis and part of the dermis, causing pain and redness.

Choice D reason: Deep full-thickness burns are also a possible answer, but full-thickness better describes the extent and characteristics given.

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Correct Answer is D

Explanation

Choice A reason: Hematuria is expected after lithotripsy and should be monitored, but it is not the most critical instruction.

Choice B reason: Using an incentive spirometer is important for respiratory care but not specific to lithotripsy.

Choice C reason: Restricting physical activities is not necessary unless advised by the healthcare provider.

Choice D reason:

The correct answer is d) because monitoring the urinary stream for a decrease in output is crucial to detect any complications such as obstruction or infection after lithotripsy.

A. Auscultate bowel sounds. B. Ambulate the client in the hallway. C. Palpate the abdomen. D. Measure hourly urine output.

Correct Answer is A

Explanation

Choice A reason:

The correct answer is a) because auscultating bowel sounds can help assess for the return of gastrointestinal function and identify potential complications such as ileus, which can cause abdominal pressure and nausea.

Choice B reason: Ambulating the client is important for postoperative recovery but does not directly address the symptoms of abdominal pressure and nausea.

Choice C reason: Palpating the abdomen is also important but should be done after auscultation to avoid altering bowel sounds.

Choice D reason: Measuring urine output is important for monitoring renal function but does not directly address the symptoms of abdominal pressure and nausea.

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The nurse is caring for a client with a burn that is severely edematous with a wound bed that is brown and yellow in appearance. The client expresses feeling no pain. Which classification of burn depth should the nurse document?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with urolithiasis is preparing for discharge after lithotripsy. Which intervention should the nurse include in the client's postoperative discharge instructions?

Correct Answer is D

Explanation

Two days after a nephrectomy, the client reports abdominal pressure and nausea. Which assessment should the nurse implement?

Correct Answer is A

Explanation

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