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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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.

B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.

C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.

D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.

A. Omeprazole B. Ondansetron C. Vancomycin D. Diphenhydramine

Correct Answer is C

Explanation

A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.

B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.

C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.

D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?

Correct Answer is D

Explanation

A nurse is reviewing the medication record for a client diagnosed with chronic kidney disease (CKD). Which of the following medications should the nurse identify as having the potential to cause nephrotoxicity?

Correct Answer is C

Explanation

A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

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?

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?