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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

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

Explanation

A. Fluid volume deficit: This is an acute phase complication. After 12 months, the client is in the rehabilitation phase, and fluid balance is typically stabilized.

B. Symptoms of post-traumatic stress: PTSD is common after severe burn trauma, especially with long hospital stays or painful treatments.

C. Depression: Chronic physical and emotional stress, changes in appearance, and functional limitations contribute to depression.

D. Electrolyte imbalances: These are more likely during the acute and early recovery phase. At 12 months, electrolyte levels are usually normalized unless other complications exist.

E. Body image disorder: Disfigurement and scarring from severe burns often result in body image disturbances, which affect emotional well-being and social reintegration.

Correct Answer is []

Explanation

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Patient presented for follow up of major burn injury. Exhibits A nurse is caring for a client recovering for 12 months from major burns that affected 60% total body surface area (TBSA). Which of the following complications should the nurse expect? (Select all that apply)

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

Explanation

Correct Answer is []

Explanation

A 65-year-old patient is admitted to the hospital with complaints of decreased urine output, fatigue, and swelling in the legs. Which of the following clinical cues is most indicative of acute kidney injury?

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?

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 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?

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?