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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
This is because tuberculosis can affect the liver and cause hepatotoxicity, especially if the client is taking anti-tuberculosis medications. The nurse should monitor the client's liver function tests, such as AST and ALT levels, and observe for signs of liver damage, such as yellow sclera, dark urine, clay-colored stools, and abdominal pain.
Correct Answer is D
Explanation
This is because immunosuppression increases the risk of infection, and health care workers can be potential sources of pathogens. The nurse should use standard precautions, avoid invasive procedures, and restrict visitors who are ill.
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