When assessing a client who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale and hard. The client states that the burn is not painful. What term would the nurse use to document the burn depth?

Superficial partial-thickness skin destruction

First-degree skin destruction

Full-thickness skin destruction

Deep partial-thickness skin destruction

Answer and Explanation

The Correct Answer is C

A. Superficial partial-thickness skin destruction: Superficial partial-thickness burns involve the epidermis and part of the dermis, causing redness, pain, and blistering. The skin is usually moist and blanches with pressure.

B. First-degree skin destruction: First-degree burns involve only the epidermis and are typically red and painful, with no blistering. The description of dry, pale, and hard skin suggests a more severe burn than a first-degree burn.

C. Full-thickness skin destruction: Full-thickness burns involve all layers of the skin (epidermis, dermis, and subcutaneous tissue). The skin appears dry, pale, and hard, and there is no pain due to nerve damage.

D. Deep partial-thickness skin destruction: Deep partial-thickness burns affect the epidermis and deeper layers of the dermis, causing blisters and pain. However, the lack of pain in this case, combined with the dry, pale, and hard skin, suggests a full-thickness burn rather than a deep partial-thickness one.

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Correct Answer is B

Explanation

A. CPR: CPR is indicated if the client becomes pulseless or unresponsive, but it is not the first-line treatment for ventricular tachycardia (VT) if the client still has a pulse. In VT with a pulse, the priority is to treat the arrhythmia through defibrillation or medications, not CPR.

B. Defibrillation: Defibrillation is the most appropriate action for VT, especially if the client becomes pulseless or unstable. VT can deteriorate into ventricular fibrillation (VF), which is life-threatening. Immediate defibrillation is required to restore normal rhythm.

C. Radiofrequency catheter ablation: Radiofrequency catheter ablation is a long-term treatment option for VT, but it is not the immediate intervention for an acute episode. It is used to target and eliminate the arrhythmogenic focus after stabilization.

D. Elective cardioversion: Elective cardioversion is used for arrhythmias like atrial fibrillation or stable supraventricular tachycardias, not for life-threatening VT. In the case of VT with a pulse, if the client is unstable, defibrillation would be more appropriate.

A. Prepare to administer Albuterol to aid the patient's breathing B. Prepare for chest tube insertion C. Prepare to apply oxygen via non-rebreather mask at 8L/Min D. Sit the patient up in high-fowler's position

Correct Answer is B

Explanation

A. Prepare to administer Albuterol to aid the patient's breathing: Albuterol is used for bronchodilation in asthma or COPD. The priority is addressing the potential life-threatening condition, such as a pneumothorax or hemothorax, indicated by the patient's tracheal deviation and labored breathing.

B. Prepare for chest tube insertion: The tracheal deviation, falling blood pressure, and labored breathing suggest a possible tension pneumothorax or hemothorax, both of which require immediate chest tube insertion. This is necessary to relieve pressure in the chest and allow the lungs to re-expand, addressing the respiratory and circulatory distress.

C. Prepare to apply oxygen via non-rebreather mask at 8L/Min: While oxygen is necessary, simply applying oxygen will not resolve the underlying mechanical issue of a tension pneumothorax. The pressure in the chest needs to be relieved for the lung to re-expand and effectively take up oxygen.

D. Sit the patient up in high-fowler's position: While sitting the patient up may help with breathing in some conditions, the most likely cause of the patient’s symptoms is a traumatic injury that requires chest tube insertion, not just positioning.

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When assessing a client who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale and hard. The client states that the burn is not painful. What term would the nurse use to document the burn depth?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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