Foundations Exam 1 Ch 32

The nurse is teaching a client about healing of a large wound by primary intention. What teaching will the nurse include? Select all that apply. a. "Your wound will be purposely left open for a time." b. "This is a simple reparative process." c. "The margins of your wound are widely separated." d. "Your wound edges are right next to each other." e. "Very little scar tissue will form."

"Very little scar tissue will form." "This is a simple reparative process." "Your wound edges are right next to each other."

The nurse is caring for a client with diarrhea caused by Clostridium difficile. Which is the priority nursing assessment for this client? a. Monitor intake and output. b. Assess the coccyx area for blanching. c. Monitor the client for nausea. d. Assess mental status.

A client with diarrhea caused by Clostridium difficile is at risk for dehydration. As such, the priority assessments should include intake and output, skin turgor, condition of mucous membranes, and vital signs. Assessing the coccyx area for blanching should be done with shift assessments; however, circulating fluid volume takes priority. Monitoring for nausea and assessing the client's mentation is not directly related to the effects of the infectious diarrhea.

Upon review of a postoperative client's medication list, the nurse recognizes that which medication will delay the healing of the operative wound? a. antihypertensive drugs b. corticosteroids c. laxatives d. potassium supplements

Clients who are taking corticosteroids or require postoperative radiation therapy are at high risk for delayed healing and wound complications. Corticosteroids decrease the inflammatory process, which may delay healing. Antihypertensive drugs, potassium supplements, and laxatives do not delay wound healing.

A postoperative client says during a transfer, "I feel like something just popped." The nurse immediately assesses for: a. infection. b. herniation. c. evisceration. d. dehiscence.

Dehiscence is a total or partial disruption of wound edges. Clients often report feeling that the incision has given way. Manifestations of infection include redness, warmth, swelling, and fever. With herniation, there is protrusion through a bodily opening. Evisceration is a term that describes protrusion of intra-abdominal contents.

The nurse is caring for a client with a sacral wound. Upon assessment, the wound is noted to have slough and a bad odor, and it extends into the muscle. How will the nurse categorize this pressure injury? a. stage II b. stage IV c. stage III d. stage I

Stage IV pressure injuries are characterized as exposing muscle and bone and may have slough and a foul odor. Stage I pressure injuries are characterized by intact but reddened skin that is unblanchable. Stage II involves blistering or a skin tear. Stage III involves a shallow skin crater that extends to the subcutaneous tissue; it may have serous or purulent drainage.

The nurse is performing frequent skin assessment at the site where cold therapy has been in place. The nurse notes pallor at the site and the client reports "it feels numb." What is the bestaction by the nurse at this time? a. Discontinue the therapy and assess the client. b. Gently rub and massage the area to warm it up. c. Notify the health care provider of the findings. d. Document the findings in the client's medical record.

The best action by the nurse at this time is to discontinue the therapy and assess the client; this should be done before notifying the health care provider or documenting the event. Gently rubbing the area or massaging it would not be appropriate at this time.

A nurse is performing negative pressure wound therapy on a client with a wound in his left ischial tuberosity area. Place in the correct order the steps that the nurse should perform during this dressing change. 1Apply a vacuum device to wound. 2Ensure that negative pressure has been achieved. 3Place the drape to cover the wound and an additional 3 to 5 cm. 4Cut a 2-cm hole in the drape. 5Use sterile gloves. 6Cut the foam to the shape and measurement of the wound.

Use sterile gloves. Cut the foam to the shape and measurement of the wound. Place the drape to cover the wound and an additional 3 to 5 cm. Cut a 2-cm hole in the drape. Apply a vacuum device to wound. Ensure that negative pressure has been achieved.

The nurse has removed the sutures and is now planning to apply wound closure strips. What should the nurse do before applying the strips? a. Apply a skin protectant to the skin around the incision. b. Apply a skin protectant to the incision site. c. Apply a transparent dressing over the incision site. d. Apply a sterile gauze sponge over the incision site.

a. Apply a skin protectant to the skin around the incision. Before applying the wound closure strips, the nurse should apply a skin protectant to the skin surrounding the incision site. The skin barrier will help the closure strips adhere to the skin and helps prevent skin irritation and excoriation from tape, adhesives, and wound drainage. The skin protectant should not be placed on the incision itself. Nothing should be placed over the incision site itself before the closure strips are applied.

A nurse is caring for a client who has a pressure injury on the left great toe. The client is scheduled for debridement the next morning. Based on the red-yellow-black (RYB) Wound Classification System, which classification should the nurse document? a. Black classification b. Unstageable c. Yellow classification d. Red classification

a. Black classification A wound that requires debridement would be classified in the black category. The red classification would indicate dressing changes for treatment. The yellow classification would indicate cleansing of the wound related to the drainage or slough in the wound. Unstageable is not a classification in the RYB Wound Classification System.

The nurse is changing the dressing of a client with a gunshot wound. What nursing action would the nurse provide? a. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. b. The nurse keeps the intact, healthy skin surrounding the ulcer moist because it is susceptible to breakdown. c. The nurse packs the wound cavity tightly with dressing material. d. The nurse uses wet-to-dry dressings continuously.

a. The nurse selects a dressing that absorbs exudate, if it is present, but still maintains a moist environment. A wound with heavy exudate will need a more absorptive dressing and a dry wound will require rehydration with a dressing that keeps the wound moist. The nurse would not keep the surrounding tissue moist. The nurse would not pack the wound cavity tightly, rather loosely. The nurse would not use wet-to-dry dressings continuously.

Which best describes the proliferative phase, the third phase of the wound healing process? a. marked by vasodilation and phagocytosis as the body works to clean the wound b. decreased number of fibroblasts, stabilized collagen synthesis, and increasing organization of collagen fibrils, resulting in greater tensile strength of the wound c. reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization d. the onset of vasoconstriction, platelet aggregation, and clot formation

c. reproduction and migration of pink epidermal cells across the surface of the wound in a process called epithelialization. In partial-thickness wounds, in the third phase, the proliferative phase, epidermal cells reproduce and migrate across the surface of the wound in a process called epithelialization. Vasoconstriction, platelet aggregation, and clot formation are part of the first phase of wound healing, hemostasis. The second phase, the inflammatory phase, is marked by vasodilation and phagocytosis as the body works to clean the wound. Maturation is the final stage of full-thickness wound healing, in which the number of fibroblasts decreases, collagen synthesis is stabilized, and collagen fibrils become increasingly organized.

A nurse is caring for a client on a medical-surgical unit who has had an evisceration of an abdominal wound after a coughing episode. Which action by the nurse is appropriate in this situation? Select all that apply. a. using sterile technique b. reinserting the protruding structures and applying a pressure dressing c. packing the wound with iodoform gauze d. covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position

covering the wound with a gauze moistened with normal saline placing the client in the low Fowler position using sterile technique.... Evisceration of a wound is a medical emergency. The client should be placed in a low Fowler position and, with the use of sterile technique, the eviscerated structures should be covered with normal saline-moistened gauze. The surgeon should also be notified. The nurse should never reinsert protruding structures or apply a pressure dressing. This could cause the tissue to be injured. The wound should not be packed with iodoform gauze. The client will have surgery to replace the eviscerated structures.

A nurse is evaluating a client who was admitted with partial-thickness or second-degree burns. Which describes this type of burn? a. Superficial, which may be pinkish or red with no blistering b. May vary from brown or black to cherry red or pearly white; bullae may be present c. A superficial partial-thickness burn, which can appear dry and leathery d. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown

d. Usually moist with blisters, which may be pink, red, pale ivory, or light yellow-brown Second-degree burns are moderate to deep partial-thickness burns that may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. First-degree burns are superficial and may be pinkish or red with no blistering. Third-degree burns are full-thickness burns and may vary from brown or black to cherry-red or pearly-white; bullae may be present; can appear dry and leathery.

The nurse is performing pressure injury assessment for clients in a hospital setting. Which client would the nurse consider to be at greatest risk for developing a pressure injury? a. a newborn b. a client with cardiovascular disease c. an older client with arthritis d. a critical care client

d. a critical care client Various factors are assessed to predicate a client's risk for pressure injury development. Client mobility, nutritional status, sensory perception, and activity are assessed. The client would also be assessed for possible moisture/incontinence issues as well as possible friction and sheer issues. Considering these factors, the individual that would be at greatest risk of developing a pressure injury would be a critical care client.

A nurse is caring for a client who has had a left-side mastectomy. The nurse notes an intact Penrose drain. Which statement about Penrose drains is true? a. A Penrose drain has a small bulblike collection chamber that is kept under negative pressure. b. A Penrose drain has a round collection chamber with a spring that is kept under negative pressure. c. A Penrose drain is a closed drainage system that is connected to an electronic suction device. d. A Penrose drain promotes passive drainage into a dressing.

A Penrose drain is an open drainage system that promotes passive drainage of fluid into a dressing. The Jackson-Pratt drain has a small bulblike collection chamber that is kept under negative pressure. A Hemovac is a round collection chamber with a spring inside that also must be kept under negative pressure

The nurse is taking care of a client who asks about wound dehiscence. It is the second postoperative day. Which response by the nurse is most accurate? a. "Dehiscence is not anything that you need to worry about." b. "Dehiscence is the softening of tissue due to excessive moisture." c. "Dehiscence is when a wound has partial or total separation of the wound layers." d. "Dehiscence is a total separation of the wound with protrusion of the viscera through it."

Dehiscence is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed. Clients at greater risk for these complications include those who are obese or malnourished, smoke tobacco, use anticoagulants, have infected wounds, or experience excessive coughing, vomiting, or straining. An increase in the flow of fluid from the wound between postoperative days 4 and 5 may be a sign of an impending dehiscence. The client may say that "something has suddenly given way." If dehiscence occurs, cover the wound area with sterile towels moistened with sterile 0.9% sodium chloride solution and notify the physician. Once dehiscence occurs, the wound is managed like any open wound.

The wound care nurse evaluates a client's wound after being consulted. The client's wound healing has been slow. Upon assessment of the wound, the wound care nurse informs the medical-surgical nurse that the wound healing is being delayed due to the client's state of dehydration and dehydrated tissues in the wound that are crusty. What is another term for localized dehydration in a wound? a. Evisceration b. Maceration c. Desiccation d. Necrosis

Desiccation is localized wound dehydration. Maceration is localized wound overhydration or excessive moisture. Necrosis is death of tissue in the wound. Evisceration is complete separation of the wound, with protrusion of viscera through the incisional area.

The nurse has received an order to apply a saline-moistened dressing to a client's wound. Which action should the nurse perform? a. Apply dry gauze pads over the wet gauze and place the abdominal pad over the gauzes. b. Apply dry gauze to the wound and carefully apply saline to saturate it. c. Exert firm pressure using forceps to pack the wound tightly with moistened dressing. d. Avoid using irrigation to clean the wound before changing the dressing.

Dry gauze is applied over wet gauze and then covered with an ABD pad. The wound should be cleaned, if needed, using sterile forceps. Irrigation may be used as ordered or required. The wound should be cleaned from the top to the bottom and from the center to the outside. The fine-mesh gauze should be placed into the basin and the ordered solution poured over the mesh to saturate it. The wound should be packed gently and loosely.

The nurse is caring for a client in the emergency department with a cut sustained 15 minutes ago while the client was preparing dinner at home. The nurse understands that the wound is in which phase of healing? a. proliferation phase b. maturation phase c. inflammatory phase d. hemostasis phase

Hemostasis is the initial phase after an injury. Hemostasis stimulates other cells to come to the wound to begin other phases of wound healing. The inflammatory phase follows hemostasis; white blood cells move into the wound to remove debris and release growth factors. The proliferation phase is the regenerative phase, in which granulation tissue is formed. The maturation phase involves collagen remodeling.

What type of dressing has the advantage of remaining in place for three to seven days, resulting in less interference with wound healing? a. hydrogel b. alginate c. transparent film d. hydrocolloid dressing

Hydrocolloids are occlusive or semi-occlusive dressings that limit exchange of oxygen between wound and environment, provide minimal to moderate absorption of drainage, maintain a moist wound environment, and may be left in place for three to seven days, thus resulting in less interference with healing. Hydrogels maintain a moist wound environment and are best for partial or full-thickness wounds. Alginates absorb exudate and maintain a moist wound environment. They are best for wounds with heavy exudate. Transparent films allow exchange of oxygen between wound and environment. They are best for small partial-thickness wounds with minimal drainage.

A nurse is caring for a client who has a wound with a large area of necrotic tissue. The health care provider has ordered fly larvae to debride the wound. Which of the following types of debridement does the nurse understand has been ordered? a. mechanical debridement b. biosurgical debridement c. autolytic debridement d. enzymatic debridement

In biosurgical debridement, fly larvae are used to clear the wound of necrotic tissue. This is accomplished by an enzyme the larvae releases. Autolytic debridement involves using the client's own body to break down the necrotic tissue. Enzymatic debridement involves the use of synthetic enzymes that break down necrotic tissue when applied to the wound bed. Mechanical debridement involves physically removing the necrotic tissue, as in surgical debridement.

An infant has sebaceous retention cysts in the first few weeks of life. The nurse documents these cysts as: a. prickly heat. b. milia. c. lanugo. d. acne vulgaris.

Milia are sebaceous retention cysts seen as white, opalescent spots around the chin and nose. They appear during the first few weeks of life and disappear spontaneously.

A nurse is caring for a postsurgical client with a Jackson-Pratt drain. Which type of wound drainage should the nurse report to the health care provider? a. copious drainage that is blood-tinged b. large amounts of drainage that is clear and watery and has no smell c. small amount of drainage that appears to be mostly fresh blood d. foul-smelling drainage that is grayish in color

Purulent drainage is frequently foul-smelling and may vary in color; such drainage is associated with infection and should be reported to the health care provider. Clear, watery (serous), blood-tinged (serosanguineous), and bloody (sanguineous) drainage are not commonly indicative of infection and may be seen in the drain during various stages of wound healing.

A nurse is providing discharge instructions for a client who had a colon resection and has a Hemovac drain in place. Which statement indicates that the client understands? a. "I will squeeze the chamber and apply the cap to maintain negative pressure." b. "I will check and empty the drain every 6 hours." c. " I will apply a dressing at the end of the drain to catch any drainage." d. "I will alternate between positive and negative pressure every 2 hours."

The Hemovac drain chamber should be squeezed and the cap applied to maintain negative pressure. The negative pressure pulls the drainage into the collection chamber. This negative pressure must be maintained continuously unless the drain is being emptied. The drain must be checked and emptied at least every 4 hours. A Penrose drain has gauze at the end of the drain to catch drainage.

A nurse is caring for a client at a wound care clinic. The client has a 5 × 6-cm abdominal wound dehiscence. Which type of wound repair would the nurse expect with this wound? a. secondary intention b. primary intention c. desiccation d. tertiary intention

The client with wound dehiscence will undergo wound repair by secondary intention. In these wounds, the wound edges are not well approximated and will require more tissue replacement. Primary intention involves wound edges that are well approximated or close together. Tertiary intention involves wounds that are left open for a period of time and then closed. Desiccation is a process in which cells are dehydrated. This leads to cell death and delays healing.

The nurse is preparing to apply an external heating pad. To be effective yet not cause damage to the underlying tissue, in which temperature range will the nurse set the pad? a. 110°F to 115°F (43.3°C to 46.1°C) b. 105°F to 109°F (40.5°C to 43°C) c. 90°F to 99°F (32.2°C to 37.2°C) d. 100°F to 104°F (37.7°C to 40°C)

The nurse should set the external heating pad in the 105°F to 109°F (40.5°C to 43°C) range, which is physiologically effective and comfortable for the client. Lower temperatures are not as effective, and higher temperatures may cause damage to the underlying skin and tissues.

The nurse is caring for a client who has a wound to the right forearm following a motor vehicle accident. The primary care provider has ordered culture of the wound. Which action should the nurse perform in obtaining a wound culture? a. Keep the swab and the inside of the culture tube sterile. b. Cleanse the wound after obtaining the wound culture. c. Utilize the culture swab to obtain cultures from multiple sites. d. Stroke the culture swab on surrounding skin first.

The swab and the inside of the culture tube should be kept sterile. The wound should be cleansed prior to obtaining the culture. The culture swab should not touch the skin surrounding the wound site. In addition, if multiple sites have to be cultured then separate culture swabs should be used.

What intervention should the nurse teach the client to support the underlying tissues and decrease discomfort after removal of surgical staples? a. To splint the area when engaging in activity b. To turn the head away from the area whenever coughing c. To remain in bed for the next 4 hours d. To ambulate using a cane or walker

To support the underlying tissues and decrease discomfort, the nurse should teach the client to splint the area when engaging in activities such as changing positions, coughing, or ambulating. Teaching the client to ambulate using a cane or walker may be necessary but is not done to support the underlying tissues or to decrease discomfort. It is done to ensure the client can use the ambulatory devices correctly. There is no indication that the client needs to stay in bed; in fact, ambulation should be encouraged. Teaching the client to turn the head away while coughing is done to aid in prevention of infection.

The nurse is preparing to apply a roller bandage to a client with a sprained knee. Which technique does the nurse plan to use? a. figure-of-eight turn b. spica turn c. circular turn d. spiral-reverse turn

a. figure-of-eight turn A figure-of-eight turn is used for joints like the elbows and knees. The other answers are incorrect.

A nurse is assessing a client's surgical wound and sees drainage that is pale pink-yellow and thin and contains plasma and red cells. What is this type of drainage? a. serosanguineous b. sanguineous c. purulent d. serous

a. serosanguineous This describes serosanguineous wound drainage. Drainage that is pale yellow, watery, and like the fluid from a blister is called serous. Drainage that is bloody is called sanguineous. Drainage that contains white cells and microorganisms is called purulent.

A client has been admitted to the acute care unit after surgery to debride an infected skin injury. The surgeon reports plans to leave the wound open to promote drainage and later close it. This represents what type of wound healing? a. tertiary intention b. primary intention c. quadratic intention d. secondary intention

a. tertiary intention Healing by tertiary intention occurs when a delay ensues between injury and wound closure. This type of healing also is referred to as delayed primary closure. It may happen when a deep wound is not sutured immediately or is purposely left open until there is no sign of infection, then closed with sutures. Wounds with minimal tissue loss, such as clean surgical incisions and shallow sutured wounds, heal by primary intention. The edges of the primary wound are approximated or lightly pulled together. Wounds with full-thickness tissue loss, such as deep lacerations, burns, and pressure injuries, have edges that do not readily approximate. They heal by secondary intention. The open wound gradually fills with granulation tissue.

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority? a. Acute pain b. Impaired tissue integrity c. Knowledge deficit d. Disturbed body image

b. Impaired tissue integrity Using the A, B, C (Airway, Breathing, Circulation) mnemonic, impaired tissue integrity takes priority. Using Maslow's Hierarchy of Needs, impaired tissue integrity also takes priority. Disturbed body image, knowledge deficit, and acute pain are all important issues that need to be addressed, but ensuring there is proper circulation to the surgical area, the surgical area is free of signs of infection, and the surgical area is intact is priority.

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate? a. Discontinue application of saline-moistened packing and apply a hydrocolloid dressing instead. b. Reduce the time interval between dressing changes. c. Assure that the packing material is completely saturated when placed in the wound. c. Use less packing material.

b. Reduce the time interval between dressing changes. Allowing the dressing material to dry will disrupt healing tissue. Therefore, the time interval between dressing changes should be reduced to prevent the dressing from drying out. Too much moisture in the dressing may cause maceration. Shortening the time interval between dressing changes is more appropriate than increasing dressing moisture. There is no indication that too much packing material was used. A hydrocolloid dressing in not indicated.

A student nurse is preparing to perform a dressing change for a pressure injury on a client's sacrum area. The chart states that the pressure injury is staged as "unstageable." Which wound description should the student nurse expect to assess? a. The wound is a 3 × 5-cm blood-filled blister. b. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. c. The wound is 3 × 5 cm, with 50 percent gray tissue and 50 percent red tissue, with subcutaneous tissue visible. d. The wound is 3 × 5 cm, with 60 percent tan tissue and 40 percent granulation tissue, with a tendon showing.

b. The wound is 3 × 5 cm, with yellow tissue covering the entire wound. The wound with yellow tissue covering the entire wound is unstageable. The depth of the wound cannot be determined, because it is covered entirely with slough. A stage III wound will have subcutaneous tissue visible. A stage IV wound will have tendon, muscle, or bone exposed. A suspected deep tissue injury presents as a maroon or purple lesion or blood-filled blister.

A client recovering from abdominal surgery sneezes and then screams, "My insides are hanging out!" What is the initial nursing intervention? a. monitoring for pallor and mottled appearance of the wound b. applying sterile dressings with normal saline over the protruding organs and tissue c. assessing for impaired blood flow to the area of evisceration. d. contacting the surgeon

b. applying sterile dressings with normal saline over the protruding organs and tissue The nurse will immediately apply sterile dressing moistened with normal saline over the protruding organs and tissue and call out for someone to contact the surgeon. While waiting for the surgeon, the nurse will continue to assess the area of evisceration and monitor the client's status.

During a skin assessment, the nurse recognizes the first indication that a pressure injury may be developing when the skin is which color during the application of light pressure? a. Yellow b. Blue-grey c. Red d. White

c. Red Nonblanching erythema is one of the earliest signs of impending skin breakdown. Blue-greyish color is pallor. Yellow is jaundice and related to liver issues. White skin is associated with no blood supply.

The nurse caring for a postoperative client is cleaning the client's wound. Which nursing action reflects the proper procedure for wound care? a. The nurse swabs the wound from the bottom to the top. b. The nurse uses friction when cleaning the wound to loosen dead cells. c. The nurse works outward from the wound in lines parallel to it. d. The nurse swabs the wound with povidone-iodine to fight infection in the wound.

c. The nurse works outward from the wound in lines parallel to it. A postoperative wound has well-approximated edges. With a postoperative wound, the nurse should work from the incision outward, in lines parallel to the incision. This method would be considered from clean to dirty. The nurse would not use friction when cleaning the wound. The nurse would not use povidone-iodine to fight infection in the wound. The nurse would not swab the wound from the bottom to the top.

A nurse is caring for a client who has a wound on the right thigh from an axe. The nurse is using the RYB wound classification system and has classified the wound as "Yellow." Based on this classification, which nursing action should the nurse perform? a. Debridement b. Gentle cleansing c. Wound irrigation d. Apply moist dressing

c. Wound irrigation With the yellow classification using the RYB wound classification system, wound irrigation should be implemented. Yellow wounds require wound cleaning and irrigation related to exudate and slough. Gentle cleansing and moist dressings are utilized in the Red classification. Debridement is required for the wounds in the Black classification because the wounds have necrotic tissue present.

To determine a client's risk for pressure injury development, it is most important for the nurse to ask the client which question? a. "How many meals a day do you eat?" b. "Have you had any recent illnesses?" c. "Do you use any lotions on your skin?" d. "Do you experience incontinence?"

d. "Do you experience incontinence?" The client's health history is an essential component in assessing the client's integumentary status and identification of risk factors for problems with the skin. The priority question addresses a source of moisture on the skin. Moisture makes the skin more susceptible to injury because it can create an environment in which microorganisms can multiply, and the skin is more likely to blister, suffer abrasions, and become macerated (softening or disintegration of the skin in response to moisture). Sound nutrition is important in the prevention and treatment of pressure injuries. The number of meals eaten per day does not give a clear assessment of nutritional status. The nurse should question the client about the skin care regimen, such as the use of lotions, but this would not be the priority in determining the risk for pressure injury development. Asking the client about any recent illnesses is not a priority in determining the risk for pressure injury development.

The nurse is caring for a client who has reported to the emergency department with a steam burn to the right forearm. The burn is pink and has small blisters. The burn is most likely: a. third degree or full thickness b. fourth degree or fat layer c. first degree or superficial d. second degree or partial thickness

d. second degree or partial thickness Partial-thickness burns may be superficial or moderate to deep. A superficial partial-thickness burn (first degree; epidermal) is pinkish or red with no blistering; a mild sunburn is a good example. Moderate to deep partial-thickness burns (second degree; dermal or deep dermal) may be pink, red, pale ivory, or light yellow-brown. They are usually moist with blisters. Exposure to steam can cause this type of burn. A full-thickness burn (third degree) may vary from brown or black to cherry red or pearly white. Thrombosed vessels and blisters or bullae may be present. The full-thickness burn appears dry and leathery.