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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Changing the ostomy pouch daily is not necessary and can lead to skin irritation. The pouch should be changed every 2-4 days or as directed by the healthcare provider.
Choice B rationale
The ostomy pouch should be emptied when it is 1/3 to 1/2 full to prevent leakage and skin irritation.
Choice C rationale
Trimming the opening of the ostomy seal to be 1/2 in. wider than the stoma is incorrect. The opening should be just slightly larger than the stoma to prevent skin irritation.
Choice D rationale
Applying lotion to the peristomal skin when changing the ostomy pouch is not recommended as it can interfere with the adhesion of the pouch.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Based on the provided exhibits, here are the considerations for the provider’s prescriptions:
- Test stools for occult blood:Anticipated. Given the client’s report of vomiting brown emesis, which could indicate gastrointestinal bleeding, testing stools for occult blood is a standard diagnostic approach to confirm or rule out bleeding.
- Insert a nasogastric tube, attach to low suction:Anticipated. The client has vomited coffee ground emesis, which is a sign of possible upper gastrointestinal bleeding. A nasogastric tube can help decompress the stomach and remove any remaining blood or gastric contents.
- Administer aspirin for abdominal pain:Contraindicated. Aspirin can exacerbate gastrointestinal bleeding, especially in a client with a history of GERD and current symptoms that may suggest a gastrointestinal bleed.
- Initiate IV fluids:Anticipated. The client’s vital signs indicate tachycardia and hypotension, which, along with the clinical presentation, suggest volume depletion possibly due to vomiting and potential bleeding. IV fluids are necessary to maintain hemodynamic stability.
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