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 []

Explanation

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

A. Administering sodium polystyrene sulfonate. B. Initiating an IV potassium infusion. C. Administering a potassium-sparing diuretic. D. Encouraging the client to eat bananas.

Correct Answer is A

Explanation

A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.

B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.

C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.

D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.

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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

Correct Answer is []

Explanation

A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Correct Answer is A

Explanation

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 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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