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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.

B. Tissue edema: Edema is subjective and can be influenced by other conditions.

C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.

D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.

A. Blistering of area B. Dry crusting surface C. Intact skin surface D. Blanching of wound area E. Pain at wound site

Correct Answer is ["A","D","E"]

Explanation

A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.

B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.

C. Intact skin surface: The skin is not intact; it is damaged and blistered.

D. Blanching of wound area: Indicates intact capillary refill and superficial depth.

E. Pain at wound site: Nerve endings are exposed, making these burns very painful.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?

Correct Answer is D

Explanation

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.)

Correct Answer is ["A","D","E"]

Explanation

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?

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 nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte Imbalances should the nurse expect?

A nurse is planning meals for a client diagnosed with chronic kidney disease (CKD). The nurse should recognize that which dietary choices are appropriate for the client?

A nurse is caring for a client who is receiving peritoneal dialysis. The nurse should monitor the client for which of the following manifestations of peritonitis?

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 developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?