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 D

Explanation

Choice A reason: The client with mitral valve stenosis experiencing heart palpitations is at risk of complications such as atrial fibrillation, which can lead to embolic events. While this is a serious condition that needs attention, it is not as immediately life-threatening as the presence of pink frothy sputum in a heart failure patient.

Choice B reason: The client with arterial occlusive disease and intermittent claudication is experiencing pain due to reduced blood flow to the extremities during activity. Although this condition requires management to prevent worsening ischemia, it is not as critical as the presentation of pink frothy sputum in a heart failure patient.

Choice C reason: The client with deep vein thrombosis (DVT) and an edematous right calf is at risk of developing a pulmonary embolism, which is a serious condition. However, the immediate symptoms do not suggest a current life-threatening emergency compared to the client with heart failure and pink frothy sputum.

Choice D reason: The client with heart failure who has pink frothy sputum must be assessed first. Pink frothy sputum is a sign of pulmonary edema, indicating severe left-sided heart failure. This condition is a medical emergency as it impairs gas exchange and can lead to respiratory failure if not promptly treated. Immediate intervention is necessary to stabilize the client's respiratory and cardiac status.

A. BP 110/62, atrial fibrillation with HR 82, bilateral basilar crackles. B. Weight gain of 1 kg in 3 days, BP 130/80, mild dyspnea with exercise. C. SpO2 92% on 2L nasal cannula, respirations 20/min, 1+ edema of lower extremities. D. Confusion, urine output 15 mL over the last 2 hours, orthopnea.

Correct Answer is D

Explanation

Choice A reason: While atrial fibrillation, bilateral basilar crackles, and a blood pressure of 110/62 indicate important findings in a client with heart failure, they are not immediately life-threatening compared to the symptoms in choice d. Bilateral crackles suggest fluid overload and pulmonary congestion, which require attention, but the priority should be on more critical signs of decreased perfusion.

Choice B reason: Weight gain of 1 kg in 3 days and mild dyspnea with exercise are signs of fluid retention and worsening heart failure. However, they are not as urgent as the symptoms of confusion and low urine output, which suggest severe hypoperfusion and potential organ failure.

Choice C reason: A SpO2 of 92% on 2L nasal cannula, respirations of 20/min, and 1+ edema of the lower extremities indicate mild hypoxemia and fluid overload. Although these findings are important and need management, they are not as critical as the symptoms in choice d, which suggest severe hypoperfusion and a potential emergency.

Choice D reason: Confusion, urine output of 15 mL over the last 2 hours, and orthopnea are the most concerning findings. Confusion indicates decreased cerebral perfusion, which is a sign of severe heart failure and possibly impending cardiogenic shock. Low urine output (oliguria) suggests poor renal perfusion, indicating that the kidneys are not receiving enough blood flow. Orthopnea (difficulty breathing while lying down) is a classic symptom of severe heart failure and pulmonary congestion. These symptoms suggest that the client is in a critical condition that requires immediate intervention to improve perfusion and prevent further deterioration.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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