The emergency room nurse is assigned the following clients at the beginning of their shift. Which client does the nurse see first?

Respiratory rate of 28/min and temperature of 101°F

Complaining of difficulty swallowing and nausea

Complaining of chest pain and diaphoretic

Blood pressure 100/60 mm Hg, right wrist painful and swollen

Answer and Explanation

The Correct Answer is C

Choice A reason: A respiratory rate of 28/min and temperature of 101°F suggest tachypnea and fever, possibly due to infection or inflammation. While concerning, these do not indicate immediate life-threatening issues like acute coronary syndrome. The ABCDE approach prioritizes circulation (chest pain) over respiratory rate, making this a lower priority.

Choice B reason: Difficulty swallowing and nausea may indicate an esophageal issue or infection but are not immediately life-threatening. These symptoms do not compromise airway, breathing, or circulation acutely in the ABCDE framework. Chest pain with diaphoresis suggests a cardiac emergency, which takes precedence due to potential for rapid deterioration.

Choice C reason: Chest pain with diaphoresis is highly suggestive of acute coronary syndrome, such as myocardial infarction, a life-threatening emergency. The ABCDE approach prioritizes circulation, and these symptoms indicate potential cardiac ischemia, requiring immediate assessment, ECG, and intervention to prevent cardiac arrest, making this the highest priority client.

Choice D reason: Blood pressure of 100/60 mm Hg with a painful, swollen wrist suggests a musculoskeletal injury with mild hypotension. While concerning, it is not immediately life-threatening compared to chest pain with diaphoresis, which may indicate acute coronary syndrome. The ABCDE approach prioritizes circulation issues like cardiac events over stable injuries.

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Correct Answer is A

Explanation

Choice A reason: Full-thickness burns destroy all skin layers, leading to scar tissue formation. Without joint alignment and mobility, scar tissue can tighten, causing contractures that limit movement. Maintaining joint alignment through positioning and therapy prevents these deformities, preserving function and reducing the risk of permanent joint immobility in burn recovery.

Choice B reason: Wound breakdown occurs due to infection or poor healing in burns but is not directly related to joint alignment. Maintaining alignment prevents contractures, not wound integrity issues. Wound breakdown is managed with infection control and dressings, making this complication unrelated to the goal of joint positioning.

Choice C reason: Heterotopic ossification involves abnormal bone growth in soft tissues, sometimes seen in severe burns, but it is not prevented by joint alignment. It results from prolonged immobility or trauma, not directly from burn scarring. Joint alignment targets contractures, making this an incorrect complication for the stated goal.

Choice D reason: Neuropathy in burns may result from nerve damage or compression but is not primarily prevented by joint alignment. Maintaining alignment focuses on preventing scar tissue contractures, not neurological complications. Neuropathy management involves pain control and monitoring, not positioning, making this unrelated to the care plan’s goal.

A. A client with a respiratory rate of 10 breaths/min B. A client who requires permanent ventilation C. A client who exhibits symptoms of dyspnea D. A client with respiratory acidosis

Correct Answer is B

Explanation

Choice A reason: A respiratory rate of 10 breaths/min is slightly below normal (12-20 breaths/min) but may not necessitate a tracheostomy unless accompanied by other factors like airway obstruction or inability to protect the airway. Tracheostomy is typically reserved for prolonged ventilation needs, not isolated low respiratory rates.

Choice B reason: A client requiring permanent ventilation, such as in chronic neuromuscular diseases or severe lung injury, needs a tracheostomy to provide a stable, long-term airway. Unlike endotracheal tubes, tracheostomies reduce complications like vocal cord damage and improve patient comfort, making them the standard for prolonged mechanical ventilation.

Choice C reason: Dyspnea, or shortness of breath, indicates respiratory distress but does not inherently require a tracheostomy. It may be managed with oxygen or non-invasive ventilation. Tracheostomy is indicated for airway obstruction or prolonged ventilation, not transient symptoms like dyspnea, which can have multiple causes.

Choice D reason: Respiratory acidosis, due to elevated CO2 from hypoventilation, may require ventilatory support but not necessarily a tracheostomy. Non-invasive ventilation or temporary intubation may suffice. Tracheostomy is reserved for long-term airway management, making it less relevant for acute acidosis without evidence of prolonged ventilation needs.

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The emergency room nurse is assigned the following clients at the beginning of their shift. Which client does the nurse see first?

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Naxlex Comprehensive Predictor Exams

While developing a care plan for a client with full thickness burns, the nurse determines an appropriate goal is to maintain alignment of joints. The goal is to prevent which of the following complications associated with full thickness burns?

Correct Answer is A

Explanation

The critical care nurse recognizes that which of the following conditions may indicate the need for a client to have a tracheostomy?

Correct Answer is B

Explanation

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