A nurse is preparing to assess a client recovered from a burning house.

Select the priority action and assessment findings critical to the assessment of this client.

Exhibits

Report from paramedics

Client was found in a bedroom under the bed of a smoke filled room. Client has first degree burns on their hands and face. Client appears anxious, vital signs as listed. An 16g IV was initiated to the Right Antecubital space and RL is infusing at 125ml/hr.

The Nurse is aware that it is critical to assess
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and knows which of the following is a critical assessment finding
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Critical to assess: A. Airway patency and signs of inhalation injury

Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.

Critical assessment finding: C. Singed nasal hairs and soot around the nares

These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.

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Correct Answer is C

Explanation

Left arm (entire): 9%

Anterior chest: 18%

Total: 9% + 18% = 27%

A. "You have a genetic tendency for the development of anemia." B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia." C. "There is a decreased production by the kidneys of the hormone erythropoietin, which is the cause of your anemia." D. "You are not eating enough iron-rich foods, which is causing anemia."

Correct Answer is C

Explanation

A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.

B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.

C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.

D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

Correct Answer is C

Explanation

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

Correct Answer is C

Explanation

A nurse is reviewing the medication record for a client diagnosed with chronic kidney disease (CKD). Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?

A nurse is preparing to administer a large dose of prescribed opioid analgesic and light sedation for a dressing change for a client with significant burn injuries. The nurse is aware that which of the following is part of preparing for the opioid analgesic and sedative administration?

A child has presented to the ER after a burn injury from a hot soup spill. Exhibits A nurse is caring for a preschooler diagnosed with a superficial partial- thickness burn on the right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?