A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Obtain a complete blood count (CBC)

Start IV fluids

Apply direct pressure

Administer pain medication

Answer and Explanation

The Correct Answer is C

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

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Correct Answer is C

Explanation

A. A combination of benzodiazepines and topical anesthetics: This is not effective for the deep and constant pain experienced with burns.

B. The use of oral opioids: Absorption may be delayed or unpredictable in critically ill burn clients.

C. A patient-controlled analgesia (PCA) system: PCA provides rapid and individualized control of pain, which is essential in the acute phase.

D. Distraction and relaxation techniques: These are supportive, not primary, strategies for severe pain.

A. Draw blood for a complete blood cell (CBC) count. B. Inspect the mouth for signs of inhalation injuries. C. Administer intravenous pain medication. D. Insert an indwelling urinary catheter.

Correct Answer is B

Explanation

A. Draw blood for a CBC: Important, but not the priority.

B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.

C. Administer intravenous pain medication: Important, but airway always comes first.

D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.

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A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?

Correct Answer is C

Explanation

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?

Correct Answer is B

Explanation

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

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A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

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A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte Imbalances should the nurse expect?

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.)