MED SURGE II EXAM 4 ACTUAL EXAM ALL QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES UPDATE ALREADY A GRADED|BRAND NEW !!{WELL REVISED}

MED SURGE II EXAM 4 ACTUAL EXAM ALL QUESTIONS AND CORRECT DETAILED ANSWERS WITH RATIONALES UPDATE ALREADY A GRADED|BRAND NEW !!{WELL REVISED} When assessing a patient who spilled hot oil on the right leg and foot, the nurse notes that the skin is dry, pale, hard skin. The patient states that the burn is not painful. What term would the nurse use to document the burn depth? a. First-degree skin destruction b. Full-thickness skin destruction C. Deep partial-thickness skin destruction d. Superficial partial-thickness skin destruction - ANSWER- ANS: B RATIONALE: With full-thickness skin destruction, the appearance is pale and dry or leathery and the area is painless because of the associated nerve destruction. Erythema, swelling, and blisters point to a deep partial-thickness burn. With superficial partial-thickness burns, the area is red, but no blisters are present. First-degree burns exhibit erythema, blanching, and pain. On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K* 4.9 mEq/L (4.8 mmol/L), and serum Na* 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. C. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusio