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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)

Causative agent and duration of exposure

Depth of burn

Anatomical location of burns on the body

Total Body Surface Area (TBSA) percentage

Time of day burn occurred

Answer and Explanation

Correct Answer : A,B,C,D

A. Causative agent and duration of exposure – Chemical, electrical, or thermal burns differ in severity.

B. Depth of burn – Superficial, partial-thickness, and full-thickness burns determine severity.

C. Anatomical location – Burns over joints, face, or perineum have higher morbidity.

D. Total Body Surface Area (TBSA) percentage – Used to estimate fluid resuscitation needs (e.g., Parkland formula).

E. Time of day burn occurred – Time does not affect burn severity.

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Correct Answer is C

Explanation

A. Sudden onset of chest pain and copious sputum

These are more consistent with pulmonary edema or a respiratory infection, not DIC.

B. Foul-smelling concentrated urine

This is suggestive of a urinary tract infection (UTI) or dehydration but is not a hallmark sign of DIC.

C. Oozing blood from IV sites & previous venipuncture sites

DIC is a disorder of excessive clotting and subsequent bleeding. Uncontrolled bleeding from IV sites, surgical wounds, or mucous membranes is a classic sign.

D. Reddened, inflamed central line catheter site

While redness around a catheter site may indicate infection, it is not a defining feature of DIC.

A. A- B. 0+ C. AB- D. A+ E. 0-

Correct Answer is ["A","E"]

Explanation

A. A
Patients with A- blood type have A antigens on their red blood cells and do not have the Rh factor (negative). They can receive A- blood because it has the same antigens and Rh factor, making it a perfect match.

B. O+
Rh-negative clients cannot receive Rh-positive blood, as it may trigger an immune reaction.

C. AB-
Type AB blood contains A and B antigens, which A- individuals do not naturally have, increasing the risk of a transfusion reaction.

D. A+
A Rh-negative (A-) client cannot receive Rh-positive (A+) blood due to the risk of Rh sensitization.

E. O-
O- blood is the universal donor for red blood cells, meaning it contains no A, B, or Rh antigens, making it safe for an A- recipient.

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For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed? (Select All that Apply.)

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Naxlex Comprehensive Predictor Exams

The nurse caring for a client with severe sepsis suspects the client may be developing disseminated intravascular coagulation (DIC). Which of the following signs and symptoms would support the diagnosis of DIC?

Correct Answer is C

Explanation

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

Correct Answer is ["A","E"]

Explanation

A patient is ordered 1 unit of packed red blood cells (250mL) to be transfused over 120 minutes. The drop factor on the tubing is 15 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (round to the nearest whole number)

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The nurse is preparing to start a transfusion of packed red blood cells. Which IV site should the nurse use?

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The nurse is caring for a patient with muffled heart sounds, jugular venous distention and hypotension. The provider diagnoses the patient with cardiac tamponade. The nurse understands that the priority of treatment for this type of shock is

The nurse is caring for a client, with no other pertinent medical history, who was burned over 709% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

Which of the following would the nurse understand is correct when implementing a primary assessment for clients suffering major trauma? The primary assessment:

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)