A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Start intravenous fluids.

Start albumin.

Check the pulses with a Doppler device.

Calculate the rule of nines.

Answer and Explanation

The Correct Answer is A

Choice A reason: Starting IV fluids is the first action to correct hypotension (72/48) and tachycardia (152) in burn shock, restoring perfusion. This aligns with burn resuscitation protocols, making it the correct action to address the client’s critical hypovolemia and absent pedal pulses immediately.

Choice B reason: Albumin is used later in burn management, not first, as crystalloids like saline restore volume. IV fluids address hypovolemia, making this incorrect, as it’s premature compared to the nurse’s priority of initiating fluid resuscitation in the burn-injured client.

Choice C reason: Checking pulses with Doppler assesses perfusion but delays fluid resuscitation needed for hypotension and shock. IV fluids are urgent, making this incorrect, as it’s secondary to the nurse’s first action of correcting hypovolemia in the burn client’s emergency care.

Choice D reason: Calculating the rule of nines guides fluid volume but is secondary to starting IV fluids for hypotension. Immediate resuscitation is critical, making this incorrect, as it delays the nurse’s priority of addressing the client’s shock state in the burn emergency.

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

Explanation

Choice A reason: Fever is common in acute cholecystitis due to gallbladder inflammation or infection. This aligns with clinical assessment findings, making it a correct manifestation the nurse would expect in a client experiencing an acute episode of cholecystitis during evaluation.

Choice B reason: Positive Cullen’s sign indicates intra-abdominal bleeding, not cholecystitis, which causes right quadrant pain. Indigestion is typical, making this incorrect, as it’s unrelated to the nurse’s expected findings in a client with acute gallbladder inflammation.

Choice C reason: Indigestion, often with bloating or nausea, supports cholecystitis, as gallstones impair bile flow. This aligns with gastrointestinal assessment, making it a correct manifestation the nurse would identify in a client with an acute cholecystitis episode.

Choice D reason: A palpable mass in the left upper quadrant suggests spleen or gastric issues, not cholecystitis, which affects the right side. Right quadrant pain is correct, making this incorrect, as it doesn’t support the nurse’s diagnosis of acute cholecystitis.

Choice E reason: Pain in the upper right quadrant, especially after fatty meals, is classic in cholecystitis due to gallbladder contraction against obstruction. This aligns with clinical findings, making it a correct manifestation the nurse would expect in acute cholecystitis assessment.

Choice F reason: Vague lower right quadrant discomfort is more typical of appendicitis, not cholecystitis, which causes upper right pain. Fatty meal-related pain is correct, making this incorrect, as it doesn’t align with the nurse’s expected findings in cholecystitis.

Choice G reason: Left upper quadrant pain suggests pancreatic or gastric issues, not cholecystitis, which is right-sided. Right quadrant pain is typical, making this incorrect, as it doesn’t support the nurse’s assessment of acute cholecystitis in the client’s presentation.

A. Increase the morphine dosage until no signs of pain or discomfort are present. B. Increase the morphine drip, but if the patient’s respiratory rate drops below 10 breaths/min, return to the original dosage. C. Gradually decrease the morphine and switch to Versed to avoid respiratory depression. D. Ask the family to leave the room because their presence is causing undue stress to the patient.

Correct Answer is B

Explanation

Choice A reason: Increasing morphine without monitoring risks respiratory depression, especially in an unresponsive patient. Titrating with a respiratory rate limit is safer, making this incorrect, as it lacks safeguards compared to the nurse’s best intervention to manage pain and avoid complications.

Choice B reason: Increasing the morphine drip to relieve grimacing while monitoring for a respiratory rate below 10 breaths/min balances pain control and safety. This aligns with palliative care protocols, making it the correct intervention for the nurse to manage the patient’s discomfort effectively.

Choice C reason: Decreasing morphine and switching to Versed may not address pain and risks withdrawal. Titrating morphine is more appropriate, making this incorrect, as it’s less effective than the nurse’s focus on maintaining pain relief while monitoring respiratory status.

Choice D reason: Asking the family to leave doesn’t address the patient’s pain or ventilator resistance. Adjusting morphine is the priority, making this incorrect, as it’s irrelevant compared to the nurse’s intervention to manage the patient’s discomfort and sedation needs.

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A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

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Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who is experiencing an acute episode of cholecystitis. Which of these clinical manifestations supports this diagnosis? (Select all that apply)

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

Explanation

Correct Answer is B

Explanation

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