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 ["C","D","E"]

Explanation

A. Calcium: Clients with CKD may have low calcium levels due to impaired vitamin D metabolism; calcium may need to be supplemented, not restricted.

B. Calories: Clients need sufficient calories to prevent catabolism. Calorie intake is typically maintained or increased, not restricted.

C. Phosphorus: Phosphorus builds up in CKD, leading to bone disorders and vascular calcification; must be limited.

D. Sodium: Sodium contributes to fluid retention and hypertension, which are problematic in CKD.

E. Protein: Protein intake is moderated (especially in non-dialysis clients) to reduce nitrogenous waste buildup, though dialysis clients may need more.

A. Bleeding may occur at injection sites when the intramuscular route is used. B. The client can experience nausea and vomiting when given oral medications. C. Pain resulting from a burn injury requires relief by the fastest route available. D. Damaged tissue and edema may interfere with drug absorption via other routes.

Correct Answer is D

Explanation

A. Bleeding may occur at injection sites when the intramuscular route is used: While possible, this is not the primary concern.

B. The client can experience nausea and vomiting when given oral medications: This may be true but is secondary to absorption issues.

C. Pain resulting from a burn injury requires relief by the fastest route available: Although IV is fast, the key issue is absorption.

D. Damaged tissue and edema may interfere with drug absorption via other routes: Burned and edematous tissue reduces IM and subcutaneous absorption, making IV the preferred route.

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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

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

Explanation

Correct Answer is D

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?

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 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?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

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)?

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 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?