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?

Medicate for pain.

Maintain the airway.

Insert an indwelling urinary catheter.

Initiate fluid resuscitation.

Answer and Explanation

The Correct Answer is B

This is because inhalation injury can cause airway edema, obstruction, and respiratory failure, which can be life-threatening. The nurse should monitor the client's respiratory status, administer oxygen, and prepare for intubation if needed.

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Correct Answer is D

Explanation

CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.

A. A crusted lesion with indurated margins. B. A small, translucent papule with rolled borders C. A multi-colored lesion with irregular borders D. A small macule with dry yellow scale

Correct Answer is B

Explanation

Basal cell carcinoma is the most common type of skin cancer and usually occurs on sun-exposed areas of the skin. It is slow-growing and rarely metastasizes. It appears as a small, translucent papule with rolled borders that may ulcerate and bleed.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has HIV. Which of the following laboratory values is the nurse's priority?

Correct Answer is D

Explanation

A nurse is assessing a client who has basal cell carcinoma on her nose. The nurse should expect which of the following findings?

Correct Answer is B

Explanation

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