The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Administer morphine 5 mg intravenously.

Administer a tetanus immunization.

Assist the client to cough and deep breathe.

Listen to breath sounds.

Answer and Explanation

The Correct Answer is D

Choice A reason: Morphine for pain is important but secondary to assessing airway and breathing in burns, as chest involvement risks respiratory compromise. Listening to breath sounds ensures stability, making this incorrect, as it’s less urgent than the nurse’s priority of respiratory assessment.

Choice B reason: Tetanus immunization prevents infection but is not urgent in acute burn management. Breath sounds assess respiratory status, critical with chest burns, making this incorrect, as it’s secondary to the nurse’s first action of ensuring airway and breathing stability.

Choice C reason: Coughing and deep breathing support respiratory function but assume stable breathing. Listening to breath sounds confirms airway patency in chest burns, making this incorrect, as it’s less immediate than the nurse’s priority of assessing respiratory status first.

Choice D reason: Listening to breath sounds is the first action to assess for respiratory compromise in deep partial thickness chest burns, as restlessness may indicate hypoxia. This aligns with burn care priorities, making it the correct action for the nurse to take initially.

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Correct Answer is D

Explanation

Choice A reason: Hyperparathyroidism causes hypercalcemia, not hypocalcemia, by increasing calcium levels. Malnutrition in alcoholism depletes calcium, making this incorrect, as it’s the opposite condition compared to the nurse’s recognition of hypocalcemia risk in the client.

Choice B reason: NSAIDs don’t significantly affect calcium levels, unlike malnutrition, which depletes calcium stores. Alcoholism increases hypocalcemia risk, making this incorrect, as it’s not a primary risk factor compared to the nurse’s evaluation of the malnourished client.

Choice C reason: Tetracycline may bind calcium but is less likely to cause hypocalcemia than chronic malnutrition. Alcoholism is a stronger risk, making this incorrect, as it’s a minor factor compared to the nurse’s recognition of hypocalcemia risk in the elderly client.

Choice D reason: A 70-year-old with alcoholism and malnutrition has the greatest hypocalcemia risk due to poor dietary calcium and vitamin D absorption. This aligns with nutritional risk factors, making it the correct client the nurse would recognize as most at risk for hypocalcemia.

A. Red meat. B. Bread. C. Citrus fruit. D. Cereal. E. Eggs. F. Salt substitutes.

Correct Answer is ["C","F"]

Explanation

Choice A reason: Red meat is not high in potassium, so it’s safe with potassium-sparing diuretics. Citrus fruits, high in potassium, risk hyperkalemia, making this incorrect, as it’s not a food the nurse would teach the client to avoid or use cautiously.

Choice B reason: Bread has low potassium content and is safe with potassium-sparing diuretics. Salt substitutes containing potassium are riskier, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use with the diuretic.

Choice C reason: Citrus fruits, like oranges, are high in potassium, risking hyperkalemia with potassium-sparing diuretics. This aligns with dietary teaching, making it a correct food the nurse would teach the client to avoid or use cautiously to prevent electrolyte imbalance.

Choice D reason: Cereal is generally low in potassium unless fortified, not requiring caution with potassium-sparing diuretics. Citrus fruits are a concern, making this incorrect, as it’s not a primary food the nurse would teach the client to limit in the diet.

Choice E reason: Eggs are low in potassium and safe with potassium-sparing diuretics. Salt substitutes pose a hyperkalemia risk, making this incorrect, as it’s not a food the nurse would include in teaching for cautious use in the client’s dietary plan.

Choice F reason: Salt substitutes often contain potassium chloride, increasing hyperkalemia risk with potassium-sparing diuretics. This aligns with dietary education, making it a correct item the nurse would teach the client to avoid or use cautiously to prevent complications.

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The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which client will the nurse recognize as having the greatest risk for development of hypocalcemia?

Correct Answer is D

Explanation

In collaboration with the registered dietitian nutritionist (RDN), which foods will the nurse teach a client who is taking a potassium-sparing diuretic to avoid or use cautiously? (Select all that apply)

Correct Answer is ["C","F"]

Explanation

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