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 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%.
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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