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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A reason: This is the correct intervention, because avoiding IM injections can prevent bleeding and hematoma formation in the client who has low platelet count and impaired clotting.

Choice B reason: This is an incorrect intervention, because obtaining a rectal temperature once per shift can cause trauma and bleeding in the rectal mucosa, which is highly vascularized and sensitive.

Choice C reason: This is an unnecessary intervention, because the client who has thrombocytopenia does not have an increased risk of infection, unless they also have neutropenia or immunosuppression. The client should be allowed to have visitors, as long as they follow the infection control precautions.

Choice D reason: This is an incorrect intervention, because encouraging daily flossing between teeth can cause gingival bleeding and ulceration in the client who has low platelet count and impaired clotting. The client should use a soft toothbrush and avoid dental floss.

A. Take allopurinol as prescribed B. Exercise several times a week C. Limit intake of foods high in purine D. Increase daily fluid intake E. Avoid lemonade

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

Explanation

The correct answer is A, C, D

Choice A reason: Allopurinol is a medication that helps reduce the production of uric acid, which is beneficial for patients with gout and urolithiasis to prevent the formation of uric acid stones.

Choice B reason: While regular exercise is generally beneficial for overall health, it does not have a direct impact on the prevention of uric acid stone formation. Therefore, it is not a specific recommendation for preventing uric acid stone.

Choice C reason: Foods high in purines can increase uric acid levels in the body, leading to the formation of uric acid stones. Limiting the intake of such foods is a key step in preventing uric acid stones.

Choice D reason: Adequate fluid intake is crucial as it helps to dilute the urine, which can prevent the formation of uric acid stones by reducing the concentration of uric acid in the urine.

Choice E reason: Contrary to the statement, lemonade may actually be beneficial in preventing uric acid stones because it contains citrate, which can help prevent stone formation. Citrate can bind to calcium and prevent stone formation, and it also makes the urine less acidic, which can help prevent the formation of uric acid stones.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 contributing to the plan of care for a client who has thrombocytopenia due to chemotherapy. Which of the following interventions should the nurse include?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client who has gout and urolithiasis. The client asks how to prevent future uric acid stones. Which of the following suggestions should the nurse make? (Select all that apply)

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

Explanation

A nurse is reinforcing teaching with a client who has stomatitis due to chemotherapy. Which of the following statements by the client indicates a need for further instruction?

A nurse is caring for a client who is scheduled to receive intermittent peritoneal dialysis. Which of the following actions should the nurse take?

A nurse is caring for a client who has thrombocytopenia and develops epistaxis. Which of the following actions should the nurse take?

A nurse is caring for a client who has continuous bladder irrigation following a transurethral resection of the prostate (TURP). Which of the following actions should the nurse take?

A nurse is reinforcing teaching with a client who has tuberculosis and a prescription for rifampin. The nurse should identify which of the following findings as a harmless and expected adverse effect of rifampin?

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?

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

A nurse is contributing to the plan of care for a client who has cancer and is scheduled to receive internal radiation therapy. Which of the following actions should the nurse recommend?