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. Metformin: When combined with contrast dye, it can increase the risk of lactic acidosis in patients with impaired kidney function; should be held before and after contrast use.
B. Atorvastatin: Though statins are metabolized hepatically, they don’t interact significantly with contrast to increase AKI risk.
C. Carvedilol: Beta-blockers do not interact with contrast dye to cause AKI.
D. Nitroglycerin: Used for angina; not associated with increased AKI risk related to contrast use.
Correct Answer is B
Explanation
A. Increased appetite: Not typical in AKI; anorexia is more common.
B. Elevated serum creatinine levels: A hallmark of AKI, indicating reduced kidney filtration capacity.
C. Hyperglycemia: Not a direct indicator of AKI, though may occur in diabetics.
D. Increased urine output: AKI is typically oliguric (low urine output) or anuric in early phases.
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