Difficulty: Medium
Average Score: 67%
Simulated
The nurse is irrigating the arm of the client with an acid burn. Which factors should prompt the nurse to continue with the irrigation? Select all that apply.
Correct answer
A,B,E
Rationale
The presence of a burning sensation may indicate that some acid remains on the skin and additional irrigation is needed. The presence of pain, even though reduced, could indicate that not all of the acid has been removed from the skin. A pH of 4.8 is acidic and indicates there is still acid residue that needs to be removed. A pH of 7 indicates a nonacidic status, which would be a positive finding. The absence of pain would indicate that all acid was removed before it could damage the skin.