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.
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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypomagnesemia: Magnesium levels are typically elevated in AKI due to reduced excretion.
B. Decreased creatinine level: Creatinine rises during the oliguric phase due to decreased filtration.
C. Hyperkalemia: Potassium accumulates in the blood during oliguria due to impaired excretion.
D. Increased glomerular filtration rate (GFR): GFR is decreased in AKI.
Correct Answer is B
Explanation
A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.
B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.
C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.
D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.
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