A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

Use aseptic technique during wound care for the client.

Obtain the client's oxygen saturation levels.

Check the client's WBC count.

Regulate IV fluids to maintain the client's urinary output.

Answer and Explanation

The Correct Answer is B

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B"},"G":{"answers":"B,C"}}

Explanation

Calcium level: Decreased due to furosemide, a loop diuretic that increases calcium excretion in the urine, leading to mild hypocalcemia.
Potassium level: Decreased due to furosemide, which causes potassium loss through diuresis. Lisinopril, an ACE inhibitor, can cause potassium retention, but in this case, the effect of furosemide dominates.
Sodium level: Decreased due to furosemide-induced diuresis, which can lead to hyponatremia by excessive sodium loss.
Edema: Improved due to furosemide, which promotes fluid removal and reduces volume overload associated with heart failure.
Oxygen saturation: Improved due to carvedilol, which reduces heart failure symptoms by decreasing myocardial oxygen demand and improving cardiac output.
Blood pressure: Lowered due to both carvedilol (a beta-blocker) and lisinopril (an ACE inhibitor), both of which reduce systemic vascular resistance.
Weight: Decreased due to both carvedilol, which helps manage fluid retention over time in heart failure, and furosemide, which directly reduces fluid overload through diuresis.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

Chronic kidney disease. The client's laboratory results show elevated BUN and creatinine levels, which are indicative of impaired kidney function. A creatinine level of 4.89 mg/dL (normal range 0.5 to 1.1 mg/dL) and BUN of 70 mg/dL (normal range 10 to 20 mg/dL) suggest a decline in kidney function, which is characteristic of chronic kidney disease (CKD). The increasing creatinine levels and the elevated BUN over time point toward worsening kidney function, which may lead to kidney failure if not managed appropriately.
Dialysis. In the setting of advanced chronic kidney disease, particularly when kidney function deteriorates to a point where the kidneys can no longer adequately filter waste products from the blood, dialysis is often required. The increasing levels of creatinine and BUN indicate that the kidneys may be unable to function properly without intervention, potentially necessitating dialysis for proper waste management and fluid balance.

Rationale for Incorrect Options:

Heart failure: While the client has some evidence of fluid retention (1+ bilateral lower extremity edema), this alone is insufficient to confirm heart failure, especially since the heart sounds were noted as normal (S1, S2, no murmur). Further assessment is needed to evaluate the heart's pumping ability, including echocardiogram or other diagnostic tests.
Hypothyroidism: Although the client has dry, flaky skin and fatigue, these symptoms are not definitive for hypothyroidism. Thyroid function tests would be necessary to confirm the diagnosis.
Anemia: Although the client has slightly low hemoglobin (13 g/dL, normal is 14 to 18 g/dL) and hematocrit, this may be due to chronic kidney disease, and it does not directly indicate anemia without further evidence, such as low iron levels or additional laboratory findings.
Diuretic therapy: While diuretics are used in heart failure or fluid overload conditions, they are not indicated here for the management of chronic kidney disease unless there is fluid retention related to heart failure or other conditions.
Thyroid replacement therapy: There is no evidence from the client's lab results or clinical presentation suggesting hypothyroidism, so thyroid replacement therapy would not be indicated at this time.
Iron supplementation: While the client has a low iron saturation (24%), this alone does not warrant iron supplementation without a definitive diagnosis of iron-deficiency anemia. Further testing would be required to confirm this.

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A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A,C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A,B"},"G":{"answers":"B,C"}}

Explanation

A nurse is assisting with the care of a client in an outpatient provider's office Exhibits Complete the following sentence by using the list of options. The nurse should identify that the client is at risk of developing dropdownand may requiredropdown

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}

Explanation

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