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A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Urinary output 25 mL/hr

Heart rate 122/min

Pain of 6 on a scale of 0 to 10

Difficulty swallowing secretions

Answer and Explanation

The Correct Answer is D

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

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Correct Answer is ["B","C"]

Explanation

A. Assessing the client's support system: Important in overall care, but not a priority in the acute phase.

B. Assessing and removing any rings or jewelry from affected limb: Jewelry can cause constriction due to swelling; removing it prevents further vascular compromise.

C. Assessing the client's circulation distal to the burn site: Circumferential burns can compromise perfusion due to edema or eschar formation. Checking pulses, cap refill, and sensation is essential.

D. Assessing the client's urine output: Important in systemic burns, but not directly related to a localized forearm burn.

E. Assessing the client's respiratory function: Critical in burns involving the face or inhalation injury, but not the forearm.

A. Calcium B. Calories C. Phosphorus D. Sodium E. Protein

Correct Answer is ["C","D","E"]

Explanation

A. Calcium: Clients with CKD may have low calcium levels due to impaired vitamin D metabolism; calcium may need to be supplemented, not restricted.

B. Calories: Clients need sufficient calories to prevent catabolism. Calorie intake is typically maintained or increased, not restricted.

C. Phosphorus: Phosphorus builds up in CKD, leading to bone disorders and vascular calcification; must be limited.

D. Sodium: Sodium contributes to fluid retention and hypertension, which are problematic in CKD.

E. Protein: Protein intake is moderated (especially in non-dialysis clients) to reduce nitrogenous waste buildup, though dialysis clients may need more.

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A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

Correct Answer is ["B","C"]

Explanation

Correct Answer is ["C","D","E"]

Explanation

A nurse is planning meals for a client diagnosed with chronic kidney disease (CKD). The nurse should recognize that which dietary choices are appropriate for the client?

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A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

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