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. 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.

A. Metformin B. Atorvastatin C. Carvedilol D. Nitroglycerin

Correct Answer is A

Explanation

A. Metformin: When combined with contrast dye, it can increase the risk of lactic acidosis in patients with impaired kidney function; should be held before and after contrast use.

B. Atorvastatin: Though statins are metabolized hepatically, they don’t interact significantly with contrast to increase AKI risk.

C. Carvedilol: Beta-blockers do not interact with contrast dye to cause AKI.

D. Nitroglycerin: Used for angina; not associated with increased AKI risk related to contrast use.

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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?

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Naxlex Comprehensive Predictor Exams

A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?

Correct Answer is B

Explanation

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. The nurse should recognize that which of the following medications taken by the client interacts with contrast material, and places the client at risk for acute kidney injury (AKI)?

Correct Answer is A

Explanation

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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.)

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A nurse is monitoring the fluid replacement of a client who has sustained burns over 40% total body surface area (TBSA). The client weight is 100kg According to the Parkland Formula, how much fluid will the client require in the first 8 hours?

A nurse is caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?

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A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

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