Correct answer—C. Rationales: Blisters should be left intact because they’re a natural barrier to infection. (Some believe that blisters should be removed for proper assessment only if they impede joint movement. If the blisters require aspiration, the outer layer should be left intact for protection.) Restrictive clothing and jewelry should be removed before edema develops. A client with a burn should receive appropriate tetanus prophylaxis. Eyebrows shouldn’t be shaved because they may not grow back.

Nursing process step: Intervention

Correct answer—C. Rationales: Frostbite occurs from overexposure to cold. It’s usually accompanied by hypothermia, which may need to be addressed first. After frostbite has occurred, it isn’t reversible; however, surrounding tissues should be protected from injury. The affected area shouldn’t be rubbed; ice crystals have formed within the tissues, and rubbing would damage the tissue further. The affected area should be immersed in warm water (100° to 110° F [37.8° to 43.3° C]).

Nursing process step: Assessment

Correct answer—C. Rationales: The sting of the Portuguese man o’ war is painful and leaves a lesion having a “string of beads” appearance on the skin. The deadliest of the jellyfish is the box jellyfish. Its sting is severe and immediately incapacitating, with wide erythematous banded lesions on the skin. Pain at the site of a lesion with a central radiation of discomfort is a hallmark of the sting of a scorpion fish. The initial sting of the Irukandji jellyfish is barely felt, and a progressive painful syndrome develops rapidly about 30 to 60 minutes after envenomation.

Nursing process step: Assessment

Correct answer—C. Rationales: A client with a core body temperature of 90° F usually doesn’t shiver. Shivering is present at higher temperatures. Clients generally don’t become apneic or have cold, pale skin until their core body temperature reaches 77° F (25° C).

Nursing process step: Assessment

Correct answer—A. Rationales: A burn client

shouldn’t receive I.M. or subcutaneous injections because of erratic drug uptake related to decreased peripheral circulation and fluid volume changes. Administration of humidified oxygen is appropriate for a trauma client but is particularly important in the severely burned client if upper airway damage is suspected. Aggressive fluid resuscitation is essential to prevent hypovolemic shock. Burns are especially prone to tetanus, and clients should receive tetanus toxoid and tetanus immune globulin on the basis of their immunization status.

Nursing process step: Intervention

Correct answer—B. Rationales: Airway, breathing, and circulation are always first priority actions. Therefore, the nurse should first assist with intubation. After the airway is stabilized, I.V. access can be attempted; if unsuccessful, the intraosseous route can be established. Epinephrine is used to treat circulation problems, but this would be addressed after the client’s airway was established. After the client is stabilized, a cervical spine X-ray can be obtained.

Nursing process step: Intervention

Correct answer—A. Rationales: The American Burn Association and the American College of Surgeons have issued guidelines outlining the categories of burn victims who should be referred to a burn center.