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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

Laterally on the left side with a pillow under the head and the right arm and hand hyperextended

Supine with a pillow under the head, and elevate the right hand and arm on a pillow

Semi-Fowler's position without a pillow under the head, and the right arm and hand elevated on a pillow

Prone without a pillow, and with the right arm and hand flexed in a position of comfort and elevated on a pillow

Answer and Explanation

The Correct Answer is C

A. Laterally on the left side

Lateral positioning may not fully prevent contractures.

B. Supine with a pillow under the head

A pillow under the head can cause neck contractures.

C. Semi-Fowler’s without a pillow, right arm & hand elevated

Prevents contractures and promotes drainage of edema.

D. Prone without a pillow

Prone position increases discomfort and risk of respiratory complications.

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Correct Answer is D

Explanation

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

A. Urine output of less than 0.5mL/kg B. Improved mental status, decreased lactate level C. A mean arterial pressure (MAP) of 65 D. A pain level of 4 or less on a scale of 0-10

Correct Answer is C

Explanation

A. Urine output of less than 0.5 mL/kg

Norepinephrine is a vasopressor used to improve perfusion. A urine output of less than 0.5 mL/kg suggests ongoing hypoperfusion and inadequate organ perfusion, which is an undesirable outcome.

B. Improved mental status, decreased lactate level

These are positive indicators of improved perfusion and oxygen delivery, but they are not the primary target for norepinephrine therapy.

C. A mean arterial pressure (MAP) of 65

A MAP of at least 65 mmHg is the target for vasopressor therapy, as it ensures adequate perfusion of vital organs.

D. A pain level of 4 or less on a scale of 0-10

While pain management is important, norepinephrine’s primary role is not pain control but rather maintaining adequate perfusion.

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How would the nurse position the client with burns of the head, neck, chest, right arm and hand to prevent contractures?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is C

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