A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Infection

Airway obstruction

Paralytic ileus

Fluid imbalance

Answer and Explanation

The Correct Answer is B

Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inﬂammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer ﬂuids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's ﬂuid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous ﬂuids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

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Correct Answer is A

Explanation

Choice A Reason: This is correct because an osmotic diuretic, such as mannitol, works by creating an osmotic gradient that draws ﬂuid from the brain tissue into the blood vessels, thereby reducing cerebral edema and intracranial pressure.

Choice B Reason: This is incorrect because an osmotic diuretic would decrease, not increase, the cell size in the brain by removing ﬂuid from the intracellular space.

Choice C Reason: This is incorrect because an osmotic diuretic would decrease, not expand, the extracellular ﬂuid volume by increasing the urine output and excreting excess ﬂuid from the body.

Choice D Reason: This is incorrect because an osmotic diuretic would not provide ﬂuid hydration, but rather cause ﬂuid loss and dehydration.

A. Contact the provider for further orders. B. Notify the blood bank of the discrepancy. C. Administer the blood as ordered. D. Complete an incident report.

Correct Answer is C

Explanation

Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.

Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.

Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.

Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.

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A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to administer an osmotic diuretic IV to a client with increased intracranial pressure. Which of the following should the nurse identify as the purpose of the medication?

Correct Answer is A

Explanation

A nurse is preparing to administer blood to a client. The unit of blood on hand is type B, and the client has type AB blood. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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A nurse is admitting a client who has acute heart failure following myocardial infarction (MI). The nurse recognizes that which of the following prescriptions by the provider requires clarification?

A nurse in an emergency department is caring for an adult client who has burns on the front and back of both his legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?