A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Estimation of burn injury

Respiratory rate

Presence of bowel sounds

Level of pain

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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Correct Answer is B

Explanation

Choice A reason: This is an incorrect instruction, because it is not necessary to take this medication for the rest of your life to prevent recurrence. Isoniazid is usually taken for 6 to 9 months, or as prescribed by the provider, to treat active TB or latent TB infection.

Choice B reason: This is the correct instruction, because your provider will monitor your liver function while you are taking this medication. Isoniazid can cause hepatotoxicity, which is a serious side effect that can damage the liver and cause jaundice, nausea, vomiting, or abdominal pain.

Choice C reason: This is an incorrect instruction, because you should avoid alcohol intake while you are taking this medication. Alcohol can increase the risk of hepatotoxicity and interfere with the metabolism of isoniazid.

Choice D reason: This is an incorrect instruction, because it is not recommended to take this medication with a meal to increase absorption. Isoniazid should be taken on an empty stomach, at least 1 hour before or 2 hours after a meal, to ensure optimal absorption and effectiveness.

A. A client who has benign prostate hyperplasia (BPH) and reports dysuria B. A client who has ulcerative colitis and reports diarrhea C. A client who has emphysema and reports dyspnea D. A client who has esophageal cancer and reports painful swallowing

Correct Answer is C

Explanation

Choice A reason: A client who has BPH and reports dysuria is not the highest priority, because dysuria is a common symptom of BPH and does not indicate an acute complication. The nurse should monitor the client's urinary output and provide comfort measures.

Choice B reason: A client who has ulcerative colitis and reports diarrhea is not the highest priority, because diarrhea is a chronic symptom of ulcerative colitis and does not indicate an acute complication. The nurse should assess the client's hydration status and electrolyte levels and administer medications as prescribed.

Choice C reason: A client who has emphysema and reports dyspnea is the highest priority, because dyspnea is a sign of respiratory distress and can indicate an acute exacerbation of emphysema. The nurse should assess the client's oxygen saturation and respiratory rate and administer oxygen therapy as prescribed.

Choice D reason: A client who has esophageal cancer and reports painful swallowing is not the highest priority, because painful swallowing is a common symptom of esophageal cancer and does not indicate an acute complication. The nurse should provide the client with soft or liquid foods and administer analgesics as prescribed.

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A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching with a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?

Correct Answer is B

Explanation

A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?

Correct Answer is C

Explanation

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