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

This is because according to the rule of nines, each arm accounts for 9 percent and each leg accounts for 18 percent of the TBSA. Therefore, burns on both arms and both legs equal (9+9+18+18) =54%.

A. Administer pantoprazole as prescribed. B. Reposition the endotracheal tube to the opposite side of the mouth daily. C. Verify the prescribed ventilator settings daily. D. Elevate the head of the bed to at least 30°. E. Apply restraints if the client becomes agitated.

Correct Answer is ["A","C","D"]

Explanation

These interventions can help prevent complications such as stress ulcers, ventilator-associated pneumonia, and aspiration. Pantoprazole reduces gastric acid secretion and protects the mucosa from erosion. Verifying the ventilator settings ensures that the client is receiving adequate oxygenation and ventilation according to their needs and goals. Elevating the head of the bed reduces the risk of aspiration and improves lung expansion.

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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

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

Correct Answer is D

Explanation

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.)

Correct Answer is ["A","C","D"]

Explanation

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