A nurse is assessing a client who has cirrhosis.
Which of the following is an expected finding for this client?

Choice A rationale

While pain management is important, maintaining the airway is the priority intervention for a client with deep partial- and full-thickness burns to the face, chest, abdomen, and upper arms. Burns to the face and chest can cause airway edema and compromise breathing.

Choice B rationale

Maintaining the airway is the priority intervention during the resuscitation phase of injury for a client with burns to the face, chest, abdomen, and upper arms. Airway edema can develop rapidly, and securing the airway is crucial to ensure adequate oxygenation and ventilation.

Choice C rationale

Inserting an indwelling urinary catheter is important for monitoring urine output and fluid balance, but it is not the priority intervention. Airway management takes precedence in this scenario.

Choice D rationale

Initiating fluid resuscitation is essential for managing burn shock and maintaining hemodynamic stability, but maintaining the airway is the priority intervention to ensure the client can breathe adequately.

Choice A rationale

Fever usually accompanies myocardial infarction. This statement is incorrect. While fever can occur with myocardial infarction, it is not a common or primary symptom. Acetaminophen is not prescribed for this reason.

Choice B rationale

Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does. This statement is correct but not the reason for prescribing acetaminophen before nitrates. Acetaminophen is chosen for its analgesic properties without affecting platelet function.

Choice C rationale

Headache is a common side effect of nitrates. This statement is correct. Nitrates can cause vasodilation, leading to headaches. Acetaminophen is prescribed to manage this common side effect.

Choice D rationale

Acetaminophen potentiates the therapeutic effect of nitrates. This statement is incorrect. Acetaminophen does not enhance the therapeutic effects of nitrates; it is used to manage side effects like headaches.