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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.

A. Areas around pins are dry. B. Crusts around pins. C. Purulent drainage around pins. D. Absence of pain at the site.

Correct Answer is C

Explanation

Choice A rationale
Areas around pins being dry is a normal finding and does not need to be reported.
Choice B rationale
Crusts around pins are also a normal finding as they are usually dried exudate and do not indicate an infection.
Choice C rationale
Purulent drainage around pins is a sign of infection. This should be reported to the unit care coordinator immediately as it may require antibiotic treatment.
Choice D rationale
Absence of pain at the site is a normal finding and does not need to be reported.

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 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 nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement. Which symptom should the nurse address first?

Correct Answer is D

Explanation

The nurse is performing pin care for a patient with an external fixation device for a fractured tibia. Which assessment finding by the nurse should be reported to the unit care coordinator?

Correct Answer is C

Explanation

A nurse is caring for a client with an electrical burn. The client states that since the wound on the skin is small, the burn must not be too bad. Which of the following is the best response by the nurse?

Which of the following are risk factors for Hepatitis B? Select all that apply.

A nurse is explaining to a client who is preparing for emergency surgery due to a small bowel obstruction. The client is anxious and doesn’t understand what the surgeon means by “adhesions” causing the blockage. Which of the following statements is the best response from the nurse?

The nursing assistant is delivering patient meals. What meal should the nurse expect to be delivered to a patient who had gastric bypass surgery the day before?

A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness. Which method should the nurse use to elicit a response from a painful stimulus?

The nurse is reviewing orders for a patient in anaphylactic shock. Which medications should the nurse plan to administer first?

A nurse is advising a client who is taking furosemide and has a serum potassium level of 3.1 mEq/L. Which food should the nurse recommend the client to incorporate into their daily diet?

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

Which of the following findings should the nurse prioritize?