A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Estimation of burn injury

Respiratory rate

Presence of bowel sounds

Level of pain

Answer and Explanation

The Correct Answer is B

Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.

Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.

Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.

Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.

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 B

Explanation

Choice A reason: This is an incorrect finding, because Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Kussmaul respirations are deep and rapid breathing that help the body eliminate excess carbon dioxide and acid.

Choice B reason: This is the correct finding, because diaphoresis is a sign of hypoglycemia, which is a condition that occurs when the blood glucose is too low. Diaphoresis is excessive sweating that results from the activation of the sympathetic nervous system and the release of epinephrine, which stimulate the body to increase the blood glucose level.

Choice C reason: This is an incorrect finding, because decreased skin turgor is a sign of dehydration, which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Decreased skin turgor is a loss of elasticity and firmness of the skin that results from the loss of fluid and electrolytes through the urine and the skin.

Choice D reason: This is an incorrect finding, because ketonuria is a sign of diabetic ketoacidosis (DKA), which is a complication of type 1 diabetes mellitus that occurs when the blood glucose is too high, not too low. Ketonuria is the presence of ketones in the urine, which are acidic substances that are produced when the body breaks down fat for energy due to the lack of insulin.

A. “Because most of my colon is still intact and functioning, my stool will be formed.” B. “My stoma will appear large at first, but it will shrink over time.” C. “My colostomy will begin to function 2 to 6 days after surgery.” D. “My diet will have to change to a soft diet after surgery.”

Correct Answer is D

Explanation

Choice A reason: This is a correct statement, because the stool consistency depends on the location of the colostomy. A sigmoid colostomy is located in the lower part of the colon, where most of the water is absorbed, so the stool will be formed.

Choice B reason: This is a correct statement, because the stoma size will decrease as the swelling subsides and the wound heals. The stoma will reach its final size in about 6 to 8 weeks after surgery.

Choice C reason: This is a correct statement, because the colostomy function will resume gradually after surgery, depending on the bowel motility and the presence of gas or stool. The colostomy will usually start to function 2 to 6 days after surgery.

Choice D reason: This is an incorrect statement, because the diet does not have to change to a soft diet after surgery. The client can resume a normal diet as tolerated, unless there are specific dietary restrictions or recommendations from the provider. A soft diet may be recommended only for the first few days after surgery, to avoid bowel obstruction or irritation.

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

A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has type 1 diabetes mellitus and a capillary blood glucose reading of 48 mg/dL. Which of the following findings should the nurse expect?

Correct Answer is B

Explanation

A nurse is reinforcing teaching with a client who is scheduled for a sigmoid colon resection with colostomy. Which of the following statements by the client indicates a need for further teaching?

Correct Answer is D

Explanation

A nurse is obtaining a weekly weight for a client who has obesity and osteoarthritis and is on a weight management program. The nurse determines that the client gained 1.36 kg (3 lb) in the past week. Which of the following statements should the nurse make?

A nurse is working with an assistive personnel (AP) who is assigned to bathe a client who has herpes zoster. The AP asks the nurse if herpes zoster is contagious. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a client who has tuberculosis (TB) and a prescription for isoniazid. Which of the following instructions should the nurse include?

A nurse is caring for a male client who is undergoing screening tests for atherosclerosis. Which of the following laboratory findings should the nurse identify as an increased risk for this disorder?

A nurse is collecting data from a client who has encephalitis due to West Nile virus. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse is monitoring a client following a thyroidectomy. Which of the following findings should the nurse identify as an indication of hypoparathyroidism?

A nurse is preparing to administer timolol eye drops for a client who has glaucoma. When instilling the medication, which of the following actions should the nurse take?

A nurse is preparing to care for a group of clients after receiving change-of-shift report. From which of the following clients should the nurse collect data first?