A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Insert an indwelling urinary catheter.

Draw blood for a complete blood cell (CBC) count.

Inspect the mouth for signs of inhalation injuries.

Administer intravenous pain medication.

Answer and Explanation

The Correct Answer is C

This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.

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Correct Answer is ["A","C"]

Explanation

Answer: A. The client has an increased risk of infection.

Rationale: This is because the client's white blood cell (WBC) count is low, which indicates a compromised immune system. The normal range for WBC is 4,000 to 11,000/mm3. A low WBC count can be caused by chemotherapy, which is a common treatment for ovarian cancer. The nurse should monitor the client for signs of infection, such as fever, chills, redness, swelling, or drainage, and implement infection prevention measures, such as hand hygiene, sterile technique, and isolation precautions.

Answer: C. The client has an increased risk for bleeding.

Rationale: This is because the client's platelet count is low, which indicates a reduced ability to form clots and stop bleeding. The normal range for platelets is 150,000 to 400,000/mm3. A low platelet count can be caused by chemotherapy, which can damage the bone marrow where platelets are produced. The nurse should monitor the client for signs of bleeding, such as petechiae, ecchymosis, hematuria, or melena, and implement bleeding prevention measures, such as avoiding invasive procedures, applying pressure to puncture sites, and using soft-bristled toothbrushes.

A. Scalp B. Genitalia C. Mouth D. Extremities

Correct Answer is C

Explanation

This is because HSV-1 typically causes oral herpes, which manifests as cold sores or fever blisters around the mouth or lips.

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A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","C"]

Explanation

A nurse is assessing a client who has viral rhinitis and a history of herpes simplex virus type 1 (HSV-1) lesions. The nurse should assess which of the following areas of the body for the recurrence of HSV-1 lesions?

Correct Answer is C

Explanation

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