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 ["125"]

Explanation

Total volume to be infused = 250 mL.

Infusion time = 2 hr.

Calculate the infusion rate in milliliters per hour (mL/hr).

Infusion rate (mL/hr) = Total volume (mL) / Infusion time (hr)

= 250 mL / 2 hr

= 125 mL/hr.

A. An unconscious adult client who has no respirations, capillary refill is >2 seconds, and paramedics have already tried to reposition airway without success. B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of <2 seconds C. A conscious adult client who has a dislocated right shoulder, respiratory rate of 18/min, and capillary refill of <2 seconds D. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of 2 seconds

Correct Answer is B

Explanation

A. This client has no respirations and delayed capillary refill, suggesting a critical lack of oxygenation. However, the lack of respirations with no success in repositioning the airway indicates that this client may be beyond resuscitation. The priority would be to address clients who are still viable for treatment.

B. This client is at risk for respiratory distress due to the sucking chest wound and requires immediate attention. The wound could lead to a pneumothorax, which compromises oxygenation. The respirations of 38/min indicate distress, but the capillary refill of <2 seconds suggests better perfusion making this client a priority for care.

C. While this client requires treatment for the dislocated shoulder, their vital signs (normal respiratory rate and good capillary refill) indicate that this client is stable. This makes them a lower priority than the unconscious client with the sucking chest wound.

D. This client is experiencing shortness of breath and has a respiratory rate of 24/min, but their capillary refill is normal. Although this client needs further assessment, they are stable compared to the unconscious client with the sucking chest wound.

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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

Correct Answer is ["125"]

Explanation

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Correct Answer is B

Explanation

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