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 C

Explanation

Choice A rationale
A DNR prescription does not mean that the patient will only receive pain medication for their treatments. A DNR order simply means that if the patient’s heart stops beating or they stop breathing, medical staff will not attempt resuscitation3.
Choice B rationale
A DNR prescription does not necessarily limit a patient’s current treatment regimen. It only specifies that CPR will not be performed in the event of cardiac or respiratory arrest. Other treatments can still be provided based on the patient’s wishes and the medical team’s recommendations3.
Choice C rationale
A DNR prescription allows a patient to continue with their current treatment regimen. The DNR order only comes into effect if the patient’s heart stops or they stop breathing3.
Choice D rationale
While a DNR prescription may limit the ability to receive invasive procedures in the event of cardiac or respiratory arrest, it does not limit other forms of treatment. The patient can still receive treatments that align with their goals of care3.

A. “This means that scar tissue formed from the healing of a past abdominal surgery is now constricting the opening in your intestine.”. B. “The most important thing is that now you are here, and it is going to get taken care of.”. C. “I will be happy to go and get you some reading materials about this procedure to explain it further.”. D. “It’s okay. It happens all the time and I’ve seen a lot of clients with this issue.”.

Correct Answer is A

Explanation

Choice A rationale
This statement accurately explains what adhesions are. Adhesions are areas of scar tissue that form between organs or tissues in the abdomen. They often form after surgery and can cause some of these loops to stick together, resulting in abdominal pain and occasionally obstruction (blockages) in the gut. In the context of a small bowel obstruction, adhesions can cause the intestines to twist or kink, similar to how a garden hose can become kinked.
Choice B rationale
While this statement may be intended to reassure the client, it does not provide the client with the information they are seeking about what adhesions are and how they are causing the blockage.
Choice C rationale
Offering to provide reading materials about the procedure does not directly answer the client’s question about what adhesions are. It may also be overwhelming for the client who is already anxious and preparing for emergency surgery.
Choice D rationale
This statement minimizes the client’s concerns and does not provide the necessary information about what adhesions are and how they are causing the blockage.

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

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Naxlex Comprehensive Predictor Exams

A client with a terminal illness asks the nurse, “If I have a DNR prescription, does that mean I will no longer receive any treatment for my condition?” Which of the following statements should the nurse provide to explain a DNR prescription?

Correct Answer is C

Explanation

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?

Correct Answer is 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?