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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

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

Explanation

A. Calcium: Clients with CKD may have low calcium levels due to impaired vitamin D metabolism; calcium may need to be supplemented, not restricted.

B. Calories: Clients need sufficient calories to prevent catabolism. Calorie intake is typically maintained or increased, not restricted.

C. Phosphorus: Phosphorus builds up in CKD, leading to bone disorders and vascular calcification; must be limited.

D. Sodium: Sodium contributes to fluid retention and hypertension, which are problematic in CKD.

E. Protein: Protein intake is moderated (especially in non-dialysis clients) to reduce nitrogenous waste buildup, though dialysis clients may need more.

A. Urinary output 25 mL/hr B. Heart rate 122/min C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing secretions

Correct Answer is D

Explanation

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

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?

Correct Answer is D

Explanation

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?

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