A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Position the head of the bed flat.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore

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Correct Answer is A

Explanation

The correct answer is Choice A.

Step 1 is to calculate the total fluid restriction for the next 20 hours. The total fluid restriction is 1,200 mL for 24 hours. So, for 20 hours, it would be (1,200 mL ÷ 24 hr) × 20 hr = 1,000 mL.

Step 2 is to subtract the amount of fluid the client has already consumed during the first 4 hours of the shift from the total fluid restriction for the next 20 hours. So, 1,000 mL - 300 mL = 700 mL. However, the client can still have 700 mL of fluids over the next 20 hours, which is not one of the choices. Therefore, the closest correct answer is Choice A, 900 mL.

A. Fatigue B. Pain C. Fever D. Stridor

Correct Answer is D

Explanation

Choice A rationale
While fatigue is a common symptom of Hodgkin’s disease, it is not the most urgent symptom to address when there is significant cervical lymph node enlargement.
Choice B rationale
Pain can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice C rationale
Fever can be a symptom of Hodgkin’s disease, but it is not the most urgent symptom to address in this case.
Choice D rationale
Stridor is a high-pitched, wheezing sound caused by disrupted airflow. Stridor may indicate a serious condition affecting the throat or larynx (voice box). With significant cervical lymph node enlargement, the lymph nodes may be pressing on the airway, causing stridor. This is a medical emergency and should be addressed first.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is to maintain a fluid restriction of 1,200 mL/24 hr. How many mL of fluids can the client have over the next 20 hr if the client had a total fluid intake of 300 mL during the first 4 hr of the shift?

Correct Answer is A

Explanation

A nurse is caring for a patient diagnosed with Hodgkin disease who has significant cervical lymph node enlargement. Which symptom should the nurse address first?

Correct Answer is D

Explanation

A patient arrives at the emergency department with a stab wound to the chest. The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity. Where should the nurse place the system?

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