A nurse is caring for a client on the medical-surgical unit.

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

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Correct Answer is C

Explanation

Left arm (entire): 9%

Anterior chest: 18%

Total: 9% + 18% = 27%

A. Fluid volume deficit B. Symptoms of Post traumatic C. Depression D. Electrolyte imbalances E. Body image disorder

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

Explanation

A. Fluid volume deficit: This is an acute phase complication. After 12 months, the client is in the rehabilitation phase, and fluid balance is typically stabilized.

B. Symptoms of post-traumatic stress: PTSD is common after severe burn trauma, especially with long hospital stays or painful treatments.

C. Depression: Chronic physical and emotional stress, changes in appearance, and functional limitations contribute to depression.

D. Electrolyte imbalances: These are more likely during the acute and early recovery phase. At 12 months, electrolyte levels are usually normalized unless other complications exist.

E. Body image disorder: Disfigurement and scarring from severe burns often result in body image disturbances, which affect emotional well-being and social reintegration.

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

Correct Answer is C

Explanation

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

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

Explanation

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A nurse is monitoring the fluid replacement of a client who has sustained burns over 40% total body surface area (TBSA). The client weight is 100kg According to the Parkland Formula, how much fluid will the client require in the first 8 hours?

A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A 65-year-old patient is admitted to the hospital with complaints of decreased urine output, fatigue, and swelling in the legs. Which of the following clinical cues is most indicative of acute kidney injury?