A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?
Urinary output 25 mL/hr
Heart rate 122/min
Pain of 6 on a scale of 0 to 10
Difficulty swallowing secretions
The Correct Answer is D
A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.
B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.
C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.
D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Maintain adequate IV hydration: The first priority in major burns is fluid resuscitation due to massive fluid shifts and risk of hypovolemic shock.
B. Administer broad-spectrum antibiotics: Not a priority during the initial resuscitative phase. Infection control comes later unless signs of sepsis appear.
C. Give IV potassium chloride: Burn patients often experience hyperkalemia initially due to cell lysis; potassium is not given early.
D. Prepare intramuscular pain medications: IM route is avoided due to poor perfusion and risk of inadequate absorption in burn patients.
Correct Answer is B
Explanation
A. Evaluating the patient's level of pain after medication administration: This is important but comes after the medication is given.
B. Ensuring a bag valve mask (BVM) is at the bedside: Opioids and sedatives depress respiratory drive. Emergency resuscitation equipment (like a BVM) must be ready in case of respiratory compromise.
C. Verification of allergies to medications: Important, but verifying allergies should already be done before administering any meds; not the priority here.
D. Documenting the level of pain before medication administration: Also important, but secondary to safety preparation.
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