The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area.
The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?
The client's pulse oximeter reading is 95 percent.
The client's urinary output is 50 mL in two hours.
The client reports a pain level of 9 out of 10.
The client has localized edema around the burn site.
The Correct Answer is B
This scenario requires applying knowledge of burn pathophysiology, fluid resuscitation, and emergency prioritization. Assessing deep tissue damage involves monitoring for systemic complications such as hypovolemia or airway compromise. Critical thinking is needed to distinguish between expected post-burn symptoms and life-threatening physiological shifts.
Choice A rationale
A saturation of 95 percent is within the acceptable normal range of 95 to 100 percent. While chest burns can impact ventilation, this specific value indicates adequate oxygenation and is not currently a priority over circulatory concerns.
Choice B rationale
Normal urinary output is ≥ 0.5 mL/kg/hr or roughly 30 mL/hr. An output of 25 mL/hr indicates poor renal perfusion or hypovolemia. This suggests inadequate fluid resuscitation, which is a life-threatening complication in major burn injuries.
Choice C rationale
Pain is expected with partial-thickness burns due to exposed nerve endings. While severe pain requires intervention, it is considered a psychosocial or non-life-threatening priority compared to hemodynamic instability or organ failure signaled by low urine output.
Choice D rationale
Localized edema is a standard inflammatory response in burn victims caused by increased capillary permeability. It is an expected finding within the first 24 to 48 hours and does not indicate an immediate systemic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Determining priority assessments in hospice care requires applying Maslow's hierarchy and the nursing process. Understanding the medical diagnosis is foundational for anticipating physical needs, managing symptoms, and ensuring safety, which precedes addressing psychosocial, spiritual, or financial concerns during the initial admission phase.
Choice A rationale
Identifying the medical diagnosis is essential for clinical decision making and symptom management. It allows the nurse to anticipate complications, understand prognosis, and provide appropriate pharmacological interventions to ensure comfort, which is the primary goal of hospice.
Choice B rationale
While financial stability affects long term care planning, it is not the immediate clinical priority upon admission. Basic physiological needs and medical stability must be addressed before the nurse evaluates the client's insurance coverage or socioeconomic status.
Choice C rationale
Spiritual assessment is a core component of holistic hospice care, yet it follows physical stabilization. The nurse must first ensure the client is not in acute physical distress before exploring religious beliefs or existential concerns.
Choice D rationale
Assessing the support system is vital for planning home care and caregiver respite. However, without understanding the medical condition first, the nurse cannot accurately determine the level of support or specific skills the family needs.
Correct Answer is A
Explanation
Hemodialysis is a renal replacement therapy used to remove metabolic waste and excess fluid. Evaluating its effectiveness requires applying knowledge of solute clearance and normal laboratory values to determine if the procedure successfully filtered toxins from the patient's blood.
Choice A rationale
The primary goal of hemodialysis is to remove nitrogenous waste products like urea. A decrease in Blood Urea Nitrogen (BUN) from elevated levels toward the normal range of 10 to 20 mg/dL indicates successful solute clearance.
Choice B rationale
Hemodialysis is designed to filter small solutes and water, not to significantly decrease the white blood cell count. A normal WBC count ranges from 5,000 to 10,000/mm. A decrease is not an expected or desired dialysis outcome.
Choice C rationale
Patients with renal failure often have low calcium. Hemodialysis typically uses a dialysate containing calcium to help normalize levels toward 9.0 to 10.5 mg/dL. A decrease in calcium is generally an adverse finding, not a therapeutic goal.
Choice D rationale
Hemodialysis does not aim to decrease red blood cell counts. Patients with chronic kidney disease often have anemia due to low erythropoietin. A decrease in RBCs would be an undesirable complication rather than a measure of effectiveness.
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