A nurse is triaging multiple clients who arrived in the emergency department from a house fire. The nurse assesses that which client has the highest priority for care?

Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds

Client with facial burns and expectorating sooty secretions in no distress

Client with dry, black skin on both hands and a history of diabetes mellitus

Client with moist blisters over the back and who reports pain as 10

Answer and Explanation

The Correct Answer is A

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

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Correct Answer is B

Explanation

A. Draw blood for a CBC: Important, but not the priority.

B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.

C. Administer intravenous pain medication: Important, but airway always comes first.

D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.

A. Skin is red, blanches, and weeps B. Skin has a leathery and dry C. Skin is waxy in appearance D. Skin is intact, dry, and red in color

Correct Answer is A

Explanation

A. Skin is red, blanches, and weeps: This is consistent with deep partial-thickness burns. These burns damage deeper layers but still allow capillary refill and exudate.

B. Skin has a leathery and dry: This is characteristic of full-thickness (third-degree) burns.

C. Skin is waxy in appearance: A waxy appearance suggests full-thickness burns.

D. Skin is intact, dry, and red in color: This indicates superficial (first-degree) burns like sunburn.

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A nurse is triaging multiple clients who arrived in the emergency department from a house fire. The nurse assesses that which client has the highest priority for care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Correct Answer is B

Explanation

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

Correct Answer is A

Explanation

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

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 assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

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?

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)