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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

Answer and Explanation

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.

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

Explanation

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

A. Hamburger on a bun and a banana B. Spaghetti and meat sauce with a breadsticks C. Carrots and spinach D. Cold cuts with bun and fresh pears

Correct Answer is B

Explanation

A. Hamburger on a bun and a banana: Bananas are high in potassium, which must be restricted in CKD. Processed hamburger meat may also be high in sodium and phosphorus.

B. Spaghetti and meat sauce with breadsticks: Pasta and meat sauce are generally low in potassium and phosphorus if made without salt substitutes. Breadsticks are low in potassium.

C. Carrots and spinach: Spinach is high in potassium and phosphorus. Cooked carrots are borderline and must be portion-controlled.

D. Cold cuts with bun and fresh pears: Cold cuts are typically high in sodium and phosphorus. Pears are generally acceptable, but the entire meal is unsuitable due to the cold cuts.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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Correct Answer is B

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