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 C

Explanation

A. Lip edema:
Concerning, but not as urgent as difficulty swallowing, which could signal airway involvement.

B. Urinary output 25 mL/hr:
Slightly low, needs monitoring, but not the immediate priority.

C. Difficulty swallowing:
Suggests edema involving the airway, possibly progressing to obstruction - this is the priority.

D. Heart rate 122/min:
May reflect pain or fluid loss, but not as urgent as a threatened airway.

A. Circular, erythematous patches on the scalp B. Scaling and redness between the toes C. Recent exposure to poison ivy D. A recent prescription for an antiseizure medication

Correct Answer is B

Explanation

A. Circular, erythematous patches on the scalp:
Describes tinea capitis, not tinea pedis.

B. Scaling and redness between the toes:
Classic symptoms of tinea pedis (athlete’s foot), a fungal infection often affecting the web spaces of toes.

C. Recent exposure to poison ivy:
Suggests allergic contact dermatitis, not fungal infection.

D. A recent prescription for an antiseizure medication:
More suggestive of Stevens-Johnson syndrome or drug reactions-not tinea pedis.

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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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