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?

Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds

Client with facial burns and expectorating sooty secretions in no distress

Client with dry, black skin on both hands and a history of diabetes mellitus

Client with moist blisters over the back and who reports pain as 10

Answer and Explanation

The Correct Answer is A

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

Explanation

A. Low serum albumin: While low albumin indicates poor nutrition or liver disease, it's not a direct cause of AKI.

B. Renal Calculi: Can cause obstruction in the urinary tract, leading to post-renal AKI.

C. Hypertension: Chronic high BP damages renal vasculature, increasing AKI risk.

D. Hypovolemia: Decreased perfusion leads to prerenal AKI.

E. Ineffective wound healing: Indicates poor nutrition or infection, but is not a primary AKI risk factor.

A. Blistering of area B. Dry crusting surface C. Intact skin surface D. Blanching of wound area E. Pain at wound site

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

Explanation

A. Blistering of area: Blisters are characteristic of superficial partial-thickness burns, involving the epidermis and part of the dermis.

B. Dry crusting surface: This is more typical of deeper burns; partial-thickness burns are moist.

C. Intact skin surface: The skin is not intact; it is damaged and blistered.

D. Blanching of wound area: Indicates intact capillary refill and superficial depth.

E. Pain at wound site: Nerve endings are exposed, making these burns very painful.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A child has presented to the ER after a burn injury from a hot soup spill. Exhibits A nurse is caring for a preschooler diagnosed with a superficial partial- thickness burn on the right forearm. Which of the following findings should the nurse expect? (Select all that apply.)

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

Explanation

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?

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