Priority nursing diagnoses for burns include: (Select All That Apply)

Adequate Tissue Perfusion

Risk for infection

Impaired Gas Exchange

Acute Pain

Fluid Volume Deficit

Answer and Explanation

Correct Answer : B,C,D,E

A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.

B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.

C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.

D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.

E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.

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Correct Answer is B

Explanation

A. "Any student who has not been infected needs to get immunized immediately."
There is no vaccine for HSV-1, so immunization is not an option.

B. "All students need to stop sharing lip products, drinks, and foods."
HSV-1 spreads through direct contact with saliva or contaminated objects, so avoiding sharing is key to prevention.

C. "Infected students need to stay out of school until the lesion is crusted over."
This is not a standard requirement for school attendance, and HSV-1 can be transmitted before lesions are visible.

D. "Students with an active lesion need to eat at a specific isolation table."
HSV-1 is not typically transmitted through casual airborne exposure; isolation tables are unnecessary and stigmatizing.

A. A client who has swelling and tenderness around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling and tenderness around the wound:
These are classic signs of infection, indicating inflammation and possible bacterial invasion.

B. Urticaria and itching around the wound:
These are signs of an allergic reaction, not infection.

C. Serosanguineous drainage from the wound:
This is normal wound drainage, especially in early healing.

D. Brown crusting over the wound:
This may indicate scab formation or dried exudate, not necessarily infection.

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Priority nursing diagnoses for burns include: (Select All That Apply)

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Naxlex Comprehensive Predictor Exams

The nurse in a high school clinic is aware of an unusually high incidences of cold sores among the student population. Which information from the nurse will be the most helpful in controlling the spread of the causative virus, HSV-1?

Correct Answer is B

Explanation

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Correct Answer is A

Explanation

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Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Priority nursing diagnoses for burns include: (Select All That Apply)

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