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 C

Explanation

Choice A reason: Inverted T waves suggest ischemia but are less specific than troponin I, which confirms myocardial damage in ACS. This is incorrect, as it’s not the most significant finding within 3 hours compared to the nurse’s reliance on biomarkers for diagnosis.

Choice B reason: Peaked T waves indicate hyperkalemia, not ACS, which is diagnosed by troponin elevation. This is incorrect, as it’s unrelated to the nurse’s expected finding for acute coronary syndrome within the first 3 hours of symptom onset.

Choice C reason: Elevated troponin I is the most significant finding for ACS, indicating myocardial necrosis within 3 hours. This aligns with diagnostic criteria, making it the correct biomarker the nurse would prioritize to confirm acute coronary syndrome in the client.

Choice D reason: Troponin T is also specific for ACS but rises slightly later than troponin I, which is detectable sooner. This is incorrect, as troponin I is more significant within 3 hours for the nurse’s diagnosis of acute coronary syndrome.

A. Hyponatremia. B. Hypocalcemia. C. Hyperkalemia. D. Hypokalemia. E. Metabolic acidosis. F. Metabolic alkalosis.

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

Explanation

Choice A reason: Sodium of 130 mEq/L indicates hyponatremia, likely from vomiting-induced sodium loss. This aligns with the child’s electrolyte profile and symptoms, making it a correct imbalance the nurse would identify as most likely based on the lab values and clinical presentation.

Choice B reason: Calcium of 9.5 mg/dL is normal, not indicating hypocalcemia. Hyponatremia and metabolic alkalosis match the labs (sodium 130, HCO3 30), making this incorrect, as it does not reflect the child’s electrolyte imbalances from vomiting and irregular pulse.

Choice C reason: Potassium of 3.3 mEq/L is low, not high, ruling out hyperkalemia. Hyponatremia and metabolic alkalosis fit the labs and vomiting history, making this incorrect, as it contradicts the child’s potassium level in the nurse’s assessment of imbalances.

Choice D reason: Potassium of 3.3 mEq/L suggests mild hypokalemia, but hyponatremia (sodium 130) is more prominent with vomiting. Metabolic alkalosis is also evident, making this partially correct but incorrect as the primary imbalance compared to hyponatremia in the child’s profile.

Choice E reason: HCO3 of 30 mEq/L indicates alkalosis, not acidosis, due to vomiting-induced hydrogen ion loss. Hyponatremia and metabolic alkalosis are correct, making this incorrect, as it contradicts the child’s alkalotic state in the nurse’s evaluation of lab values.

Choice F reason: HCO3 of 30 mEq/L indicates metabolic alkalosis, common with vomiting due to loss of acidic gastric contents. This, with hyponatremia, aligns with the child’s labs and symptoms, making it a correct imbalance the nurse would identify in the assessment.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

A child has a 2-day history of vomiting, hypoactive bowel sounds, and an irregular pulse. Electrolyte values are sodium, 130 mEq/L; potassium, 3.3 mEq/L; calcium, 9.5 mg/dL; and HCO3, 30 mEq/L. Which of the following imbalances is the child most likely to have? (Select all that apply)

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

Explanation

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