BURNS
The nurse is caring for a patient with 50% total body surface area burns. Which finding indicates that burn shock is resolving? A. Heart rate 112 bpm B. Respirations 24 per minute C. Blood pressure 90/60 mm Hg D. Urine output 800 mL over 2 hours
D. Urine output 800 mL over 2 hours
The client sustained a hot grease burn to the right hand and calls the emergency room for advice. Which information should the nurse provide to the client? 1. Apply an ice pack to the right hand. 2. Place the hand in cool water. 3. Be sure to rupture any blister formation. 4. Go immediately to the doctor's office.
2. Place the hand in cool water.
A patient weighing 187 lbs. has 38% total body surface area burns. Using the Advanced Burn Life Support resuscitation guidelines, how much fluid should this patient receive over the first 8 hours after the burn occurred? Record the answer as a whole number.
3,230 mL
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
He has an electrical burn. He is stable, and we will update you with any changes.
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
Hyperkalemia
A nurse is preparing to start and IV infusion of Lactated Ringer's for a client who sustained a burn injury. The client is prescribed 5,200 ml of fluid over the first 24 hours. How many mL/hour should the nurse set the pump to infuse for the first 8 hours?
325 ml/hr
The ED nurse is caring for a client admitted with extensive, deep partial-thickness and full-thickness burns. Which interventions should the nurse implement? List in order of priority. 1. Estimate the amount of burned area using the rule of nines. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 4. Determine the client's airway status. 5. Administer morphine sulfate, a narcotic analgesic, IV.
4, 2, 3, 1, 5. 4. Determine the client's airway status. 2. Insert two (2) 18-gauge catheters and begin fluid replacement. 3. Apply sterile saline dressings to the burned areas. 1. Estimate the amount of burned area using the rule of nines. 5. Administer morphine sulfate, a narcotic analgesic, IV.
The client with full-thickness burns to 40% of the body, including both legs, is being transferred from a community hospital to a burn center. Which measure should be instituted before the transfer? 1. A 22-gauge intravenous line with normal saline infusing. 2. Wounds covered with moist sterile dressings. 3. No intravenous pain medication. 4. Adequate peripheral circulation to both feet ensured.
4. Adequate peripheral circulation to both feet ensured.
A patient with 35% total body surface area burns is in the rehabilitative phase of care. Which approach should be used to reduce the risk of developing contractures? A. Apply splints B. Physical therapy two hours a day C. Passive range of motion exercises D. Occupational therapy one hour every other day
A. Apply splints
A patient recovering from 25% total body surface area burns has a low-grade fever. What actions are the priority for the nurse to reduce this patient's risk of developing an infection? A. Following contact precautions B. Implementing protective isolation C. Using sterile technique for all dressing changes D. Administering prophylactic antibiotics as prescribed
A. Following contact precautions
A patient weighing 187 lbs. has 38% total body surface area burns. Using the Parkland formula, how much fluid should this patient receive over the first eight hours after the burn occurred? Record your answer as a whole number.
6460
In caring for a patient who sustained chemical burns, the nurse correlates which as potential causes of these injuries? Select all that apply. A. Lime B. Gasoline C. Bleach D. Fabric softer E. Hydrofluoric acid
A, B, C, E
The nurse provides care to a patient who is in the emergency department (ED) with a burn injury. What is the priority action by the nurse during the emergent phase of care? A. Providing pain medications B. Placing an indwelling urinary catheter C. Administering the prescribed high-flow 100% oxygen by mask D. Inserting two large-bore intravenous catheters in preparation for fluid resuscitation
C. Administering the prescribed high-flow 100% oxygen by mask
The nurse is assisting with the secondary survey of a patient with 50% total body surface area electrical burns. Which test would be a priority for this patient? A. Chest x-ray B. Bronchoscopy C. Computed tomography (CT) scan of the head D. 12-lead electrocardiogram
D. 12-lead electrocardiogram
A nurse is an emergency room is caring a client who sustained partial-thickness burns to both lower legs, chest, face and both forearms. Which of the following is the priority action the nurse should take?
Inspect the mouth for sings of inhalation injuries
A nurse is providing dietary teaching for a client who has a burn injury and adheres to a vegan diet . The nurse should recommend which of the following foods as the best source of protein to promote wound healing?
One cup of lentils
a nurse is caring for a preschooler who has partial-thickness burn on her right forearm. Which of the following findings should the nurse expect?
sensitive to touch wound blanches with pressure blisters
A client who is having burn debridement states, "You are the worst nurse I have ever seen. All you do is hurt me." Which of the following responses should the nurse make appropriate?
"Tell me more about that."
A patient is diagnosed with several superficial partial-thickness burns. What treatment would be indicated for this patient if the blisters are broken? Select all that apply. A. Apply bacitracin ointment. B. Cover with a nonadherent bandage. C. Apply mafenide acetate 10% cream. D. Wash with antiseptic soap and warm water. E. Apply collagenase and cover with roll gauze.
A, B, D
A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention? A. Airway obstruction B. Infection C. Fluid imbalance D. Paralytic ileus
A. Airway obstruction
The nurse is preparing an educational tool to instruct community members on burn prevention. What does the nurse include as the most common injury in children younger than age 5? A. Scald B. Flame C. Chemical D. Carbon monoxide poisoning
A. Scald
A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse preform first?
Administer IV fluids
A nurse is caring for a client who has burns to his face, ears and eyelids. The nurse should identify which of the following is the priority finding to report to the provider? A. Urinary output 25mL/hr B. Difficulty swallowing C. HR 122 beats/min D. Lip edema
B. Difficulty swallowing
The nurse is evaluating nutritional teaching provided to a patient recovering from 24% total body surface area burns. Which information indicates that teaching has been effective? A. Weight loss 3 kg B. Serum protein level 7.1 g/dL c. Serum albumin level 2.8 g/dL d. +1 pitting edema of lower extremities
B. Serum protein level 7.1 g/dL
The nurse is evaluating the nutritional status of a patient recovering from 24% total body surface area burns. Which data indicate adequate nutritional status? A. Urine output of 50 mL/hour B. Serum protein level 7.1 g/dL C. Serum albumin level 2.8 g/dL D. +1 pitting edema of lower extremities
B. Serum protein level 7.1 g/dL
A patient presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this patient? A. Pathway of flow through the body B. Duration of contact with the agent C. Type, dose, and length of exposure D. Temperature to which the skin is heated
C. Type, dose, and length of exposure
In providing care to a patient admitted with a suspected inhalation injury, what nursing action in the priority? A. Administering intravenous lactated Ringer's fluid B. Turning in bed every 2 hours C.Monitoring intake and output D. Administering 100% humidified oxygen
D. Administering 100% humidified oxygen
In providing care to a victim of a car fire who is confused, dizzy, and nauseated, the nurse recognizes the need for which diagnostic test to determine if this patient is experiencing carbon monoxide poisoning? A. Arterial blood gas (ABG) B. Bronchoscopy C. Pulse oximeter D. Carboxyhemoglobin level
D. Carboxyhemoglobin level
A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?
Erythema
nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
Lactated Ringers
A nurse in an emergency department is caring for a client who has deep-partial and full-thickness burns to his chest, abdomen and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?
Maintaining the airway
A nurse is assessing a client who is brought to the emergency room with burn injuries. Which of the following findings should the nurse identify as deep partial-thickness burn?
The burned area is red in color with eschar present.
The client asks about ways to prevent carbon monoxide poisoning. Which teaching will the nurse provide? a. "You can see black smoke when carbon monoxide is in the air." b. "If you are experiencing carbon monoxide poisoning, your skin will begin turning blue." c. "The only way to get poisoned from carbon monoxide gas is if you are in the presence of a fire." d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."
d. "It is important to have carbon monoxide detectors in your home, because this is an odorless gas."
Which assessment finding does the nurse interpret as demonstrating a client's fluid resuscitation adequacy? a. Decreased skin turgor b. Decreased pulse pressure c. Decreased core body temperature d. Decreased urine specific gravity
d. Decreased urine specific gravity
In providing care to a patient with 70% total body surface area chemical burns, the nurse correlates which as most effective in meeting this patient's nutritional needs? A. Parenteral nutrition B. Duodenal tube feedings C. Nasogastric tube feedings D. Six small high-calorie meals per day
B. Duodenal tube feedings
The nurse provides care to a patient who sustained burns on 75% of the body. Which data requires the nurse to notify the healthcare provider? A. Pain rating of 8 on a 1 to 10 point scale B. Heart rate 90 bpm C. Urine output 2 mL/kg per hour D. Blood pressure 96/50 mm Hg
D. Blood pressure 96/50 mm Hg
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicate that additional fluid resuscitation is required? A. Blood pH 7.39 B. HR 112 C. Blood pressure 110/60 mm Hg D. Central venous pressure 2 mm Hg
D. Central venous pressure 2 mm Hg
The nurse is evaluating care provided to a patient with burns during the emergent phase. Which data indicate that additional fluid resuscitation is required? A. Blood pH 7.39 B. Heart rate 112 bpm C. Blood pressure 110/60 mm Hg D. Central venous pressure 2 mm Hg
D. Central venous pressure 2 mm Hg
A nurse is assessing the depth and extent of a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the first priority when assessing the severity of the burn? A. Age of the client B. Associated medical history C. Location of the burn D. Cause of the burn
C. Location of the burn
An adult patient received burns over both upper and lower arms, both hands, anterior upper and lower legs, anterior chest, and the neck. Using the following as a guide, what is this patient's total body surface percentage of area burned?
67
A patient has been recovering for 18 months from burns that affected 60% total body surface area. For which complications does the nurse provide care to this patient? Select all that apply. A. Hyperkalemia B. Depression C. Fluid volume deficit D. Body imagine disorder E. PTSD
A, B, D, E
A victim of a house fire is brought to the emergency department for burn treatment. The nurse correlates which assessment to an inhalation injury? A.Coughing B. Soot on the face C. Singed facial hair D. Heart rate 98 bpm
C. Singed facial hair
A patient with several deep partial-thickness burns asks how long it will take for the burn to heal. What is the nurse's best response? A. "More than 2 weeks." B. "Within 1 to 2 weeks." C. "Within 24 to 72 hours." D. "You will need skin grafts."
A. "More than 2 weeks."
A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment data does the nurse correlate to successful wound care treatment? A. Gray wound bed B. Separation of eschar C. Development of eschar D. Presence of purulent exudate
B. Separation of eschar
a nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Witch of the following interventions should the nurse anticipate the healthcare provider to prescribe?
Place a bed cradle on the client's bed
A nurse is caring for a toddler who arrives at the emergency department with burns to his lower legs. Which of the following actions should the nurse take?
Pour tepid water over the burns.
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.
A, C, D a. Place client in isolation. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client.
The school nurse is preparing material for National Fire Prevention Week. What information should be added to the classroom posters? Select all that apply. A. Never leave a burning candle unattended. B. Set heating pads on "low" when sleeping. C. Keep a flashlight and telephone near the bed. D. Check smoke alarm batteries every 12 months. E. Never use the oven as a method to warm the home.
A, C, E A. Never leave a burning candle unattended. C. Keep a flashlight and telephone near the bed. E. Never use the oven as a method to warm the home.
Which nursing intervention(s) decrease(s) the risk for cross-contamination in the client with a severe burn injury? (Select all that apply.) a. Place client in isolation. b. Encourage multiple visitors to support client. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client. e. Change gloves after cleaning and dressing of one wound area, before cleaning and dressing another.
A,C,D a. Place client in isolation. c. Ensure that no plants or flowers are in the client's room. d. Teach family members not to bring fresh fruits and vegetables to the client.
The nurse is encouraging range-of-motion exercises for the client, who states, "this hurts terribly; I don't want to do this." Identify the appropriate nursing response(s). (Select all that apply.) a. "You have to do the exercises to get well." b. "Range-of-motion helps promote mobility." c. "Just visualize a beach to get your mind off of the pain." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?" f. "The health care provider has ordered these exercises, and it is important that you do them as instructed."
B, D, E b. "Range-of-motion helps promote mobility." d. "Let me check when you were last given pain medication." e. "What techniques for pain management have you used in the past that were helpful?"
A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which of the following clients should the nurse care for first? A. A conscious adult client who reports shortness of breath, has a respiratory rate of 24/min, and capillary refill of < 2 seconds 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. An unconscious adult client who has no respirations, capillary refill is > 2 seconds, and paramedics have already tried to reposition airway without results
B. An unconscious adult client who has a sucking chest wound, respirations of 38/min, and capillary refill of < 2 seconds
The nurse is caring for a patient with 45% total body surface area thermal burns. The nurse monitors for which laboratory result? A. Increased pH B. Increased sodium (NA+) C. Increased potassium (K+) D. Decreased hematocrit
C. Increased potassium (K+)
A patient recovering from deep and full thickness burns is nauseated. Which medication should the nurse provide to help this patient? A. Ranitidine (Zantac) B. Esomeprazole (Nexium) C. Metoclopramide (Reglan) D. Polyethylene glycol (Miralax)
C. Metoclopramide (Reglan)
A patient is ending the first year of recovery after having burns to both legs. Which observation indicates that the patient needs to be encouraged to wear the pressure garment? A. Skin warm and moist B. Pedal pulses present but faint C. Scattered areas of scarring noted D. Nonpitting edema of both ankles
C. Scattered areas of scarring noted
A victim of a house fire is brought to the emergency department for burn treatment. What assessment finding indicates that the patient may have an inhalation injury? A. Coughing B. Soot on the face C. Singed facial hair D. HR 98 bpm
C. Singed facial hair
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support? A. Assign assistive personnel to keep his room neat and clean B. Rotate nursing staff so he can have varied interactions C. Talk with him during wound care D. Keep family members aware of his condition
C. Talk with him during wound care
A patient with 55% total body surface area burned received two-thirds of the required fluid resuscitation. For which potential problem should the nurse prepare to provide care to this patient? A. Increased zone of stasis B.Increased zone of hyperemia C.Increased zone of coagulation D. Decreased zone of coagulation
C.Increased zone of coagulation
A patient is admitted for a suspected inhalation injury. What should the nurse emphasize when caring for this patient? A. Increase oral fluids B. Turn in bed every two hours C. Monitor strict intake and output D. Deep breathing and coughing every hour
D. Deep breathing and coughing every hour
The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome? A. Potential for undiagnosed injuries B. Injuries from being thrown bruise soft tissue C. Electrical current alters integrity of blood vessels D. Fluid seeps from intravascular spaces into the interstitium
D. Fluid seeps from intravascular spaces into the interstitium
The nurse is caring for a patient who sustained electrical burns. What is the rationale for monitoring this patient for compartment syndrome? A.Potential for undiagnosed injuries B.Injuries from being thrown bruise soft tissue C.Electrical current alters integrity of blood vessels D.Fluid seeps from intravascular spaces into the interstitium
D. Fluid seeps from intravascular spaces into the interstitium
The nurse is caring for a patient who sustained electrical burns. Why should the nurse monitor this patient for compartment syndrome? A. Potential for undiagnosed injuries B. Injuries from being thrown bruise soft tissue C. Electrical current alters integrity of blood vessels D. Fluid seeps from intravascular spaces into the interstitium
D. Fluid seeps from intravascular spaces into the interstitium
In caring for patient with 50% total body surface area burns, the nurse correlates which finding to resolution of burn shock? A. Heart rate 112 bpm B.Respiration 24 per minute C.Blood pressure 90/60 mm Hg D.Urine output 800 mL over 2 hours
D. Urine output 800 mL over 2 hours
A nurse is caring for a client who full-thickness burns all over 75% of his body. Which of the following methods is appropriate to accurately monitor the cardiovascular system?
Monitor the pulmonary artery pressure
A patient recovering from full-thickness burns rates pain as a 9 on a scale of 0 to 10 when hydrotherapy is performed. For which type of pain should this patient be treated? A. Referred B. Procedural C. Background D. Breakthrough
B. Procedural
Which nursing interventions should be included for the client who has full-thickness and deep partial-thickness burns to 50% of the body? Select all that apply. 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 4. Change invasive lines once a week. 5. Administer antibiotics as prescribed.
1, 2, 3, 5 1. Perform meticulous hand hygiene. 2. Use sterile gloves for wound care. 3. Wear gown and mask during procedures. 5. Administer antibiotics as prescribed.
The client is admitted with full-thickness and partial-thickness burns to more than 30% of the body. The nurse is concerned with the client's nutritional status. Which intervention should the nurse implement? 1. Encourage the client's family to bring favorite foods. 2. Provide a low-fat, low-cholesterol diet for the client. 3. Monitor the client's weight weekly in the same clothes. 4. Make a referral to the hospital social worker.
1. Encourage the client's family to bring favorite foods.
The intensive care unit (ICU) burn nurse is developing a nursing care plan for a client with severe full-thickness and deep partial-thickness burns over half the body. Which client problem has priority? 1. High risk for infection. 2. Ineffective coping. 3. Impaired physical mobility. 4. Knowledge deficit
1. High risk for infection.
The client has full-thickness burns to 65% of the body, including the chest area. After establishing a patent airway, which collaborative intervention is priority for the client? 1. Replace fluids and electrolytes. 2. Prevent contractures of extremities. 3. Monitor urine output hourly. 4. Prepare to assist with an escharotomy.
1. Replace fluids and electrolytes.
The nurse writes the nursing diagnosis "impaired skin integrity related to open burn wounds." Which intervention would be appropriate for this nursing diagnosis? 1. Provide analgesia before pain becomes severe. 2. Clean the client's wounds, body, and hair daily. 3. Screen visitors for respiratory infections. 4. Encourage visitors to bring plants and flowers.
2. Clean the client's wounds, body, and hair daily.
The client has sustained severe burns on both the anterior right and left leg and the anterior chest and abdomen. According to the rule of nines, what percentage of the body has been burned?
36%
A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the clients total body surface area? (TBSA)
54%
The nurse provides care to a 40-year-old patient with burns on 24% of the body. The patient's current weight is 110 lbs. (50 kg). The patient received fluid resuscitation for 8 hours using the Advanced Burn Life Support (ABLS) guidelines. At what rate (mL/hour) does the nurse set the pump for the patient to receive the remaining fluid over the next 16 hours? Record as a number with no units of measurement.
75 mL/hr
The nurse administers a large dose of the prescribed opioid analgesic in preparation for a dressing change for a patient with significant burn injury. What is the nurse's priority in this situation? A. Ensuring a bag and mask is at the bedside B. Asking the patient, "Are you allergic to any medications?" C. Documenting the level of pain before medication administration D. Evaluating the patient's level of pain after medication administration
A. Ensuring a bag and mask is at the bedside
A patient recovering from 25% total body surface area burns has a low-grade fever. What should the nurse do to reduce this patient's risk of developing an infection? A. Follow contact precautions B. Implement protective isolation C. Use sterile technique for all dressing changes D. Administer prophylactic antibiotics as prescribed
A. Follow contact precautions
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. the clients spouse asks the nurse what the procedure entails. Which of the following statements is appropriate? A. Large incisions will be made in the eschar to improve circulation B. I can call the doctor back if you want me to C. A piece of skin will be removed and grafted over the burned area D. Dead tissue will be surgically removed
A. Large incisions will be made in the eschar to improve circulation
A patient has full-thickness burns over 30% of total body surface area. Which intervention to address the patient's comfort does the nurse question? A. Elevate injured extremities. B. Medicate for pain around the clock. C. Apply medicated ointment to all areas. D. Elevate the head of the bed 30 degrees.
B. Medicate for pain around the clock.
A nurse is monitoring a client who was admitted with a sever burn injury and is receiving IV fluid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
Heart rate
The client comes into the emergency room in severe pain and reports that a pot of boiling hot water accidentally spilled on his lower legs. The assessment reveals blistered, mottled red skin, and both feet are edematous. Which depth of burn should the nurse document? 1. Superficial partial thickness. 2. Deep partial thickness. 3. Full thickness. 4. First degree.
2. Deep partial thickness.
The nurse provides care to an adult patient with burns over 36% of the body. The patient's current weight is 110 lbs. (50 kg). Using the Advance Burn Life Support guidelines, what is the total volume the patient needs to receive in the first 24 hours after the burn?
3,600 mL
The client is scheduled to have a xenograft to a left lower-leg burn. The client asks the nurse, "What is a xenograft?" Which statement by the nurse would be the best Response? 1. "The doctor will graft skin from your back to your leg." 2. "The skin from a donor will be used to cover your burn." 3. "The graft will come from an animal, probably a pig." 4. "I think you should ask your doctor about the graft."
3. "The graft will come from an animal, probably a pig."
The client is being discharged after being in the burn unit for six (6) weeks. Which strategies should the nurse identify to promote the client's mental health? 1. Encourage the client to stay at home as much as possible. 2. Discuss the importance of not relying on the family for needs. 3. Tell the client to remember that changes in lifestyle take time. 4. Instruct the client to discuss feelings only with the therapist.
3. Tell the client to remember that changes in lifestyle take time.
The nurse is applying mafenide acetate (Sulfamylon), a sulfa antibiotic cream, to a client's lower extremity burn. Which assessment data would require immediate attention by the nurse? 1. The client complains of pain when the medication is administered. 2. The client's potassium level is 3.9 mEq/L and sodium level is 137 mEq/L. 3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20. 4. The client is able to perform active range-of-motion exercises.
3. The client's ABGs are pH 7.34, PaO2 98, PaCO2 38, and HCO3 20.
The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area. Which assessment data would warrant notifying the health-care provider? 1. The client is complaining of severe pain. 2. The client's pulse oximeter reading is 95%. 3. The client has T 100.4˚F, P 100, R 24, and BP 102/60. 4. The client's urinary output is 50 mL in two (2) hours.
4. The client's urinary output is 50 mL in two (2) hours.
A patient with deep partial-thickness wounds is receiving enzymatic debridement. What assessment made by the nurse would indicate that wound care treatment has been successful? A. Grey wound bed B. Separation of eschar C. Development of eschar D. presence of purulent drainage
B. Separation of eschar
The nurse monitors for which assessment findings in the patient admitted with superficial partial-thickness burns over both anterior lower arms? A. Dry with no blisters B. Waxy appearance and cherry red color C. Dry leathery appearance and pale or brown color D. Open or closed blisters, mild edema, easily blanches
D. Open or closed blisters, mild edema, easily blanches
