A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?

The client is producing black colored sputum.

The client has large blistered areas over his chest.

The client has edema at the burn site.

The client has decreased sensation over the burn areas.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.

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

Explanation

Choice A rationale
Pancreatitis can lead to gastrointestinal bleeding. Inflammation of the pancreas can cause damage to the organ’s blood vessels, leading to bleeding. This can be a serious complication of pancreatitis.
Choice B rationale
Peptic ulcer disease is a common cause of gastrointestinal bleeding. Ulcers are sores that develop on the lining of the stomach, upper small intestine, or esophagus. When these ulcers erode into blood vessels, bleeding can occur.
Choice C rationale
Inflammatory bowel disease (IBD), which includes conditions like Crohn’s disease and ulcerative colitis, can cause ulcers in the digestive tract. These ulcers can bleed, leading to gastrointestinal bleeding.
Choice D rationale
Gastrointestinal malignancy, or cancer, can cause gastrointestinal bleeding. Tumors can erode into blood vessels or cause ulcers that bleed.
Choice E rationale
Diverticulosis involves the formation of small pouches in the wall of the digestive tract. These pouches can bleed, leading to gastrointestinal bleeding.
Choice F rationale
Gallbladder disease typically does not cause gastrointestinal bleeding. The gallbladder stores bile, a fluid produced by the liver to digest fats. While gallstones and inflammation of the gallbladder are common, they do not usually lead to gastrointestinal bleeding.
Choice G rationale
Hypothyroidism, a condition in which the thyroid gland does not produce enough thyroid hormone, is not typically associated with gastrointestinal bleeding. Symptoms of hypothyroidism can include fatigue, weight gain, and depression, but not gastrointestinal bleeding.

Correct Answer is ["167"]

Explanation

To calculate the rate for the infusion pump, you would divide the total volume by the total time, then multiply by the drop factor. Here’s how you can do it: Step 1 is: Calculate the total volume in mL, which is 1000 mL.

Step 2 is: Calculate the total time in minutes. Since there are 60 minutes in an hour, 2 hours is 120 minutes.

Step 3 is: Divide the total volume by the total time. So, 1000 mL ÷ 120 min = 8.33 mL/min.

Step 4 is: Multiply the result by the drop factor. If we assume a standard drop factor of 20 drops/mL, then (8.33 mL/min) × 20 drops/mL = 166.67 drops/min. So, the nurse should set the infusion pump to approximately 167 drops per minute. Vital signsVital signs Explore

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A nurse is assessing a client with a major burn injury. Which of the following findings should the nurse prioritize?

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Naxlex Comprehensive Predictor Exams

Which of the following conditions could potentially lead to a gastrointestinal bleed? (Select all that apply.)

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

Explanation

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Correct Answer is ["167"]

Explanation

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A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?