A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest.

What is the primary risk to the client?

Contractures

Fluid imbalance

Airway obstruction

Infection .

Answer and Explanation

The Correct Answer is C

Choice A rationale
Contractures, or the shortening and hardening of muscles, tendons, or other tissue, can be a complication of burns. However, they are not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice B rationale
While fluid imbalance can occur with any burn due to loss of fluid from the damaged skin, it is not typically the primary risk for a patient with burns on the head, neck, and chest.
Choice C rationale
Airway obstruction is a primary risk for a patient with burns on the head, neck, and chest. Swelling from the burns can lead to obstruction of the airway, making it difficult for the patient to breathe.
Choice D rationale
While infection is a risk with any burn, it is not typically the primary risk for a patient with burns on the head, neck, and chest. The primary risk is airway obstruction due to swelling from the burns.

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Correct Answer is B

Explanation

Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.

A. “A DNR prescription means you will only receive pain medication for your treatments.”. B. “A DNR prescription will limit your current treatment regimen.”. C. “A DNR prescription will allow you to continue with your current treatment regimen.”. D. “A DNR prescription will limit your ability to receive invasive procedures.”. .

Correct Answer is C

Explanation

Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.

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A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest. What is the primary risk to the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?

Correct Answer is B

Explanation

A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

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A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest.

What is the primary risk to the client?