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.
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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D"]
Explanation
A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.
B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.
C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.
D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.
E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.
Correct Answer is A
Explanation
A. Metformin: When combined with contrast dye, it can increase the risk of lactic acidosis in patients with impaired kidney function; should be held before and after contrast use.
B. Atorvastatin: Though statins are metabolized hepatically, they don’t interact significantly with contrast to increase AKI risk.
C. Carvedilol: Beta-blockers do not interact with contrast dye to cause AKI.
D. Nitroglycerin: Used for angina; not associated with increased AKI risk related to contrast use.
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