A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Difficulty swallowing

Urinary output 25 mL/hr

Heart rate 122/min

Pain of 6 on a scale of 0 to 10

Answer and Explanation

The Correct Answer is A

Difficulty swallowing is the priority finding to report to the provider. Rationale: This is because difficulty swallowing can indicate airway edema, which can compromise breathing and oxygenation. The nurse should monitor the client's respiratory status and administer oxygen as prescribed. The other findings are also important, but not as urgent as airway obstruction.

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Correct Answer is D

Explanation

CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.

A. Instruct the client to use pursed-lip breathing. B. Provide the client with a low-protein diet. C. Have the client use the early-morning hours for exercise and activity. D. Restrict the client's fluid intake to less than 2 L/day.

Correct Answer is A

Explanation

This is because pursed-lip breathing helps to prevent air trapping and promote gas exchange by creating positive pressure in the airways. The nurse should also teach the client to exhale slowly and completely through pursed lips. The other interventions are not appropriate for a client who has COPD.

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A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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