A nurse is preparing to assess a client recovered from a burning house.

Select the priority action and assessment findings critical to the assessment of this client.

Exhibits

Report from paramedics

Client was found in a bedroom under the bed of a smoke filled room. Client has first degree burns on their hands and face. Client appears anxious, vital signs as listed. An 16g IV was initiated to the Right Antecubital space and RL is infusing at 125ml/hr.

The Nurse is aware that it is critical to assess
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and knows which of the following is a critical assessment finding
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Critical to assess: A. Airway patency and signs of inhalation injury

Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.

Critical assessment finding: C. Singed nasal hairs and soot around the nares

These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.

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Correct Answer is D

Explanation

Formula: 4 mL × Body weight (kg) × %TBSA

4 × 100 × 40 = 16,000 mL total in 24 hours

Half (8,000 mL) is given in the first 8 hours

Answer- 8000ml

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds B. Client with facial burns and expectorating sooty secretions in no distress C. Client with dry, black skin on both hands and a history of diabetes mellitus D. Client with moist blisters over the back and who reports pain as 10

Correct Answer is A

Explanation

A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.

B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.

C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.

D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is triaging multiple clients who arrived in the emergency department from a house fire. The nurse assesses that which client has the highest priority for care?

Correct Answer is A

Explanation

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. The nurse should recognize that which of the following medications taken by the client interacts with contrast material, and places the client at risk for acute kidney injury (AKI)?

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?

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?

A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

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?

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