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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 D

Explanation

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

A. D-dimer, fibrinogen and fibrin degradation products. B. Fibrin degradation products lactic acid, and complete blood count. C. Complete blood count platelets and prothrombin time. D. Prothrombin time, form level and dimer

Correct Answer is A

Explanation

A. D-dimer, fibrinogen, and fibrin degradation products is correct because these tests reflect the excessive clotting and fibrinolysis seen in DIC: D-dimer: Elevated due to fibrin breakdown. Fibrinogen: Decreased due to excessive consumption. Fibrin degradation products (FDPs): Increased due to breakdown of fibrin clots.

B. Fibrin degradation products, lactic acid, and complete blood count is incorrect because lactic acid is more useful in sepsis evaluation, not DIC diagnosis.

C. Complete blood count, platelets, and prothrombin time is incorrect because while platelets may be low and PT may be prolonged, these tests alone are not specific for DIC.

D. Prothrombin time, form level, and d-dimer is incorrect because “form level” is not a relevant test, and PT alone is not sufficient for DIC diagnosis.

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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

A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?

Correct Answer is D

Explanation

The nurse is viewing orders for a client with a suspected diagnosis of disseminated intravascular coagulation (DIC). The marse recognizes that which laboratory test order set will most effectively guide the provider to a diagnosis of DIC?

Correct Answer is A

Explanation

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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.

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