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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

Identifying life-threatening complications in immunocompromised patients is critical. Knowledge of the systemic inflammatory response syndrome and hemodynamic instability in neutropenic patients must be applied to differentiate between oncological emergencies like sepsis, tumor lysis syndrome, and superior vena cava obstruction.

Choice A rationale

Sepsis in neutropenic patients often leads to septic shock, characterized by hypotension (80/40 mm Hg) and tachycardia (142/min). The high fever and rapid breathing indicate a systemic response to infection and inadequate tissue perfusion.

Choice B rationale

Tumor lysis syndrome results from rapid cell destruction, causing hyperkalemia, hyperuricemia, and renal failure. While it is an oncological emergency, it does not typically present with the acute hemodynamic collapse and profound hypotension seen in this scenario.

Choice C rationale

While chemotherapy induces fatigue, it does not cause severe hypotension, high fever, or extreme tachycardia. These findings represent a critical physiological crisis rather than the expected side effects of exhaustion or malaise during oncological treatment.

Choice D rationale

Superior vena cava syndrome involves obstruction of blood flow from the upper body, causing facial edema, neck vein distention, and dyspnea. It does not primarily present with acute fever, sepsis symptoms, or profound hypotension.

A. Obtain a CT scan of the brain without contrast. B. Obtain a CT scan with contrast. C. Administer a thrombolytic agent. D. Begin intravenous hydration.

Correct Answer is A

Explanation

Acute stroke management requires rapid application of the time-is-brain principle. Knowledge of the differential diagnosis between ischemic and hemorrhagic strokes is vital. Practitioners must prioritize diagnostic imaging that safely identifies hemorrhage to determine if thrombolytic therapy is indicated.

Choice A rationale

A non-contrast CT scan is the gold standard for initial stroke assessment to rule out intracranial hemorrhage. It is faster than an MRI and avoids contrast, which can mimic blood or cause kidney injury in emergencies.

Choice B rationale

Contrast is avoided during the initial emergency scan because it can leak into brain tissue and appear hyperdense. This mimics the appearance of acute blood, making it difficult to distinguish between a bleed and ischemia.

Choice C rationale

Thrombolytics cannot be administered until a CT scan confirms the absence of a hemorrhage. Giving these drugs to a patient with a brain bleed would cause catastrophic worsening of the condition and potential death.

Choice D rationale

While IV access and hydration are important, they are secondary to identifying the type of stroke. Diagnostic imaging must occur first to facilitate the most time-sensitive treatments like fibrinolysis or mechanical thrombectomy for ischemia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A client presents to the emergency department with a sudden onset of left-sided weakness, difficulty speaking, and a facial droop on the left side. Which action should the nurse prioritize?

Correct Answer is A

Explanation

The nurse is supervising a nursing student who is providing care for a thoracotomy patient with a chest tube. Which finding requires immediate reporting?

A nurse is caring for an adult client on the medical-surgical unit who is receiving anticoagulant therapy for a recent pulmonary embolism. Which action should the nurse take first?

The nurse is caring for the terminally ill client. Which interventions should the nurse implement to help minimize the stress and frustration experienced by the client and their family? Select all that apply.

A client is admitted to the emergency department following a motor vehicle accident. Which nursing actions should the nurse take during the primary survey?

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take?

The nurse plans care for a client with a traumatic brain injury who exhibits signs of post-concussion syndrome, including headaches, irritability, and sleep disturbances. Which strategy should the nurse include in the client's care plan?

A client with a severe traumatic brain injury is exhibiting signs of dysphagia. What should the nurse do first to ensure safe feeding?

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?