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. A weeping vesicle:
More typical of eczema or contact dermatitis, not basal cell carcinoma.

B. A red, edematous macule:
Suggests inflammation or allergic reaction, not a basal cell lesion.

C. A rough, scaly tumor:
Describes squamous cell carcinoma or actinic keratosis.

D. A pearly, shiny nodule with defined borders:
Classic presentation of basal cell carcinoma, especially on sun-exposed areas.

A. Cool the burn with ice water. B. Administer opioid analgesics. C. Administer systemic antibiotics. D. Keep extremities elevated. E. Remove all sheets and coverings.

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

Explanation

A. Cool the burn with ice water:
Never use ice on burns. It can cause vasoconstriction and worsen tissue injury.

B. Administer opioid analgesics:
Severe pain is common in burn injuries. IV opioids are preferred for rapid onset and titration.

C. Administer systemic antibiotics:
Burn injuries compromise the skin barrier, increasing the risk of infection. Systemic antibiotics may be necessary to prevent or treat infections.

D. Keep extremities elevated:
Elevating extremities helps reduce edema and improve venous return.

E. Remove all sheets and coverings:
Sheets may provide warmth and protection. Removing them indiscriminately may worsen hypothermia or cause further trauma to the skin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is inspecting a lesion on a client who has basal cell carcinoma. Which of the following findings should the nurse expect?

Correct Answer is D

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A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.

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

Explanation

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