A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?

The client is producing black colored sputum.

The client has large blistered areas over his chest.

The client has edema at the burn site.

The client has decreased sensation over the burn areas.

Answer and Explanation

The Correct Answer is A

Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.

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Correct Answer is B

Explanation

Choice A rationale
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the esophagus, irritating the lining and causing symptoms like heartburn. Protonix (pantoprazole) is a proton pump inhibitor that decreases the amount of acid produced in the stomach. While it is used to treat GERD, it is not typically used prophylactically in trauma patients.
Choice B rationale
Stress ulcers are a type of peptic ulcer that is particularly common in critically ill or severely stressed patients, such as those with severe trauma like an automobile accident. These ulcers occur when the body’s physical stress leads to increased gastric acid secretion, which can damage the gastric mucosa and lead to ulcers. Protonix, by reducing stomach acid, can help prevent these ulcers in high-risk patients. This is why it is often administered prophylactically in severe trauma cases.
Choice C rationale
Dumping syndrome is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. It’s also known as rapid gastric emptying. Protonix is not typically used to prevent dumping syndrome.
Choice D rationale
Gastritis is an inflammation of the stomach lining. While Protonix can be used to treat gastritis, it is not typically used prophylactically for this condition in trauma patients.

A. Test stools for occult blood B. Insert a nasogastric tube, attach to low suction C. Administer aspirin for abdominal pain D. Initiate IV fluids

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Based on the provided exhibits, here are the considerations for the provider’s prescriptions:

Test stools for occult blood:Anticipated. Given the client’s report of vomiting brown emesis, which could indicate gastrointestinal bleeding, testing stools for occult blood is a standard diagnostic approach to confirm or rule out bleeding.
Insert a nasogastric tube, attach to low suction:Anticipated. The client has vomited coffee ground emesis, which is a sign of possible upper gastrointestinal bleeding. A nasogastric tube can help decompress the stomach and remove any remaining blood or gastric contents.
Administer aspirin for abdominal pain:Contraindicated. Aspirin can exacerbate gastrointestinal bleeding, especially in a client with a history of GERD and current symptoms that may suggest a gastrointestinal bleed.
Initiate IV fluids:Anticipated. The client’s vital signs indicate tachycardia and hypotension, which, along with the clinical presentation, suggest volume depletion possibly due to vomiting and potential bleeding. IV fluids are necessary to maintain hemodynamic stability.

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A nurse is assessing a client with a major burn injury. Which of the following findings should the nurse prioritize?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient has severe trauma from an automobile accident. The nurse is checking the gastric pH and is administering Protonix 40 mg IV piggyback two times a day as ordered. This is prophylactic to prevent which of the following?

Correct Answer is B

Explanation

A nurse is admitting a client. Review the exhibits to answer the question. Exhibits For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

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A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?