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.
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Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is D
Explanation
A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.
B. Tissue edema: Edema is subjective and can be influenced by other conditions.
C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.
D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.
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