A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

The client produces black colored sputum.

The client has decreased sensation over the burn areas.

The client has edema at the burn site.

The client has large blistered areas over his chest.

Answer and Explanation

The Correct Answer is A

A. The client produces black colored sputum.
Black sputum indicates inhalation injury, which can compromise the airway-this is a life-threatening emergency and takes priority.

B. The client has decreased sensation over the burn areas.
This is expected in deep partial- or full-thickness burns but is not immediately life-threatening.

C. The client has edema at the burn site.
Edema is common after burns due to capillary leakage and inflammation.

D. The client has large blistered areas over his chest.
While concerning, this is not a higher priority than potential airway compromise.

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Correct Answer is D

Explanation

A. Firm nodule with crust:
Suggests squamous cell carcinoma, not melanoma.

B. Pearly papule with an ulcerated center:
Classic for basal cell carcinoma, not melanoma.

C. Rough, dry and scaly:
Suggestive of actinic keratosis, a precursor to squamous cell carcinoma.

D. Irregularly shaped, irregular borders, brown, tan and black coloring:
This is typical of malignant melanoma, which often appears as an asymmetrical lesion with variegated color and irregular borders.

A. Any student who has not been infected needs to get immunized immediately. B. All students need to stop sharing lip products, drinks, and foods. C. Infected students need to stay out of school until the lesion is crusted over. D. Students with an active lesion need to eat at a specific isolation table.

Correct Answer is B

Explanation

A. "Any student who has not been infected needs to get immunized immediately."
There is no vaccine for HSV-1, so immunization is not an option.

B. "All students need to stop sharing lip products, drinks, and foods."
HSV-1 spreads through direct contact with saliva or contaminated objects, so avoiding sharing is key to prevention.

C. "Infected students need to stay out of school until the lesion is crusted over."
This is not a standard requirement for school attendance, and HSV-1 can be transmitted before lesions are visible.

D. "Students with an active lesion need to eat at a specific isolation table."
HSV-1 is not typically transmitted through casual airborne exposure; isolation tables are unnecessary and stigmatizing.

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A nurse is collecting data on a client who has a major burn injury. The nurse should recognize which of the following findings as a priority?

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Naxlex Comprehensive Predictor Exams

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