A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

Instruct the client to exercise the fingers and wrist.

Call the healthcare provider to report the loss of the radial pulse.

Continue to assess the arm every hour for any additional changes.

Administer morphine IV.

Answer and Explanation

The Correct Answer is B

Choice A reason: Instructing the client to exercise the fingers and wrist is not the immediate priority. While maintaining mobility is important in burn care, the absence of a radial pulse indicates a potential vascular compromise that needs urgent attention.

Choice B reason: Calling the healthcare provider to report the loss of the radial pulse is the correct and immediate action. The absence of a radial pulse suggests that the edema is causing compartment syndrome, which can lead to tissue ischemia and necrosis if not promptly treated. This is a medical emergency requiring immediate intervention, possibly including a fasciotomy to relieve pressure.

Choice C reason: Continuing to assess the arm every hour for additional changes is important, but it is not the immediate priority. The absence of a radial pulse indicates a critical issue that needs immediate reporting and intervention, rather than waiting for further changes.

Choice D reason: Administering morphine IV can help manage the client's pain, which is significant at 8/10. However, it does not address the underlying issue of the absent radial pulse and potential compartment syndrome. Pain management is important but secondary to resolving the vascular compromise.

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Correct Answer is J

Explanation

Choice A reason: Carbon monoxide poisoning occurs when carbon monoxide binds to hemoglobin, preventing oxygen from binding and leading to hypoxia. Symptoms include headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion. However, a hoarse voice and a brassy cough are not typical symptoms of carbon monoxide poisoning. These symptoms are more indicative of an inhalation injury due to direct thermal or chemical damage to the airway.

Choice B reason: Pulmonary edema refers to fluid accumulation in the lungs, which can cause difficulty breathing, a feeling of suffocating or drowning, and a cough that produces frothy sputum. Although pulmonary edema can occur after significant burn injuries due to fluid resuscitation or other complications, the specific symptoms of a hoarse voice and brassy cough are more suggestive of an inhalation injury than pulmonary edema.

Choice C reason: An inhalation injury is

The correct answer. This type of injury occurs when a patient inhales smoke, hot gases, or toxic chemicals during a fire. Symptoms can include a hoarse voice, brassy cough, stridor, and respiratory distress. The hoarseness and brassy cough are classic signs of damage to the upper airway due to the inhalation of hot gases or smoke, leading to swelling and irritation of the airway tissues.

Choice D reason: Bacterial pneumonia is an infection of the lungs that can cause symptoms such as fever, chills, cough with phlegm, shortness of breath, and chest pain. While pneumonia can develop as a secondary complication in burn patients, the immediate symptoms of a hoarse voice and brassy cough are more indicative of an inhalation injury rather than bacterial pneumonia.

A. Serum potassium (K) and sodium (Na) levels. B. Temperature and blood pressure. C. Daily weight and edema. D. Serum creatinine (Cr) and blood urea nitrogen (BUN) levels.

Correct Answer is D

Explanation

Choice A reason: Monitoring serum potassium and sodium levels is important in many clinical situations, but it is not the primary concern when administering Vancomycin. Vancomycin can cause nephrotoxicity, which is best assessed by monitoring kidney function indicators such as serum creatinine and blood urea nitrogen levels.

Choice B reason: Temperature and blood pressure should be monitored regularly in patients receiving IV medications, especially antibiotics, to detect signs of infection or adverse reactions. However, the specific priority when administering Vancomycin is monitoring for nephrotoxicity, which is more accurately assessed through serum creatinine and BUN levels.

Choice C reason: Daily weight and edema monitoring are important for assessing fluid balance and potential heart or kidney issues. While useful, these are not the primary markers for detecting complications related to Vancomycin administration.

Choice D reason: Serum creatinine and blood urea nitrogen levels are critical indicators of kidney function. Vancomycin can cause nephrotoxicity, so monitoring these levels helps detect any signs of kidney injury early, ensuring appropriate adjustments to the medication regimen to prevent further damage.

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A client is admitted to the emergency department with a full-thickness burn to the right arm. Upon assessment, the arm is edematous, the fingers are mottled, and the radial pulse is now absent. The client states that the pain is 8/10. What is the priority action the nurse should take?

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Naxlex Comprehensive Predictor Exams

Correct Answer is J

Explanation

The client is receiving IV doses of Vancomycin every 12 hours. Which would be the nurse's priority to monitor for complications during the period that the patient is receiving this drug?

Correct Answer is D

Explanation

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