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 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.

A. The client has an increased risk of infection. B. The client should receive a diet with increased protein. C. The client has an increased risk for bleeding. D. The client should receive an erythropoiesis stimulating agent.

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

Explanation

Answer: A. The client has an increased risk of infection.

Rationale: This is because the client's white blood cell (WBC) count is low, which indicates a compromised immune system. The normal range for WBC is 4,000 to 11,000/mm3. A low WBC count can be caused by chemotherapy, which is a common treatment for ovarian cancer. The nurse should monitor the client for signs of infection, such as fever, chills, redness, swelling, or drainage, and implement infection prevention measures, such as hand hygiene, sterile technique, and isolation precautions.

Answer: C. The client has an increased risk for bleeding.

Rationale: This is because the client's platelet count is low, which indicates a reduced ability to form clots and stop bleeding. The normal range for platelets is 150,000 to 400,000/mm3. A low platelet count can be caused by chemotherapy, which can damage the bone marrow where platelets are produced. The nurse should monitor the client for signs of bleeding, such as petechiae, ecchymosis, hematuria, or melena, and implement bleeding prevention measures, such as avoiding invasive procedures, applying pressure to puncture sites, and using soft-bristled toothbrushes.

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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

Correct Answer is A

Explanation

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

Explanation

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