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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
The femoral pulse is located in the groin area and is often used during procedures or when other pulse sites are not available. It does not directly assess circulation to the brain.
Choice B rationale
The radial pulse, located on the thumb side of the wrist, is commonly used to measure heart rate but does not directly assess circulation to the brain.
Choice C rationale
The carotid pulse is located on either side of the neck below the jawline. It is one of the major arteries that supply blood to the brain. In an emergency, this pulse site is used to assess circulation to the brain.
Choice D rationale
The popliteal pulse is located behind the knee and is used to assess circulation to the lower leg. It does not directly assess circulation to the brain.
Correct Answer is B
Explanation
Choice A rationale
Avoiding intramuscular injections is not typically a component of patient education for iron deficiency anemia. Intramuscular injections do not have a direct impact on iron absorption or utilization.
Choice B rationale
Including orange juice when taking iron supplements is often recommended. The vitamin C in orange juice can enhance the absorption of iron, making it more available for the body to use. This is particularly important in iron deficiency anemia, where the body needs more iron to produce sufficient red blood cells.
Choice C rationale
Avoiding green leafy vegetables is not usually advised for patients with iron deficiency anemia. In fact, green leafy vegetables are a good source of iron and are often recommended as part of a diet for someone with this condition.
Choice D rationale
Avoiding live immunizations is not typically a part of patient education for iron deficiency anemia. The condition does not affect the immune response to vaccines, nor do vaccines interfere with iron absorption or utilization.
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