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The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Deep purple erythema

Facial nerve deficits

Dysphonia or dysphagia

Heart rate of 10 and blood pressure of 96/68

Answer and Explanation

The Correct Answer is C

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

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Correct Answer is ["70"]

Explanation

Formula: Dose = Weight (kg) × 80 units/kg
5600 units ÷ 80 units/kg = 70 kg

A. Fluid resuscitation B. Transfer to a burn center C. Application of sterile dressings D. Administer morphine 8mg IV.

Correct Answer is A

Explanation

A. Fluid resuscitation

Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.

B. Transfer to a burn center

While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.

C. Application of sterile dressings

Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.

D. Administer morphine 8 mg IV

Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.

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The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A heparin IV bolus is ordered: 80 units per kilogram. The unit's pharmacist prepares & labels a dose of heparin that is 5600 units. What is the patient's weight in kilograms? _______________

Correct Answer is ["70"]

Explanation

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Correct Answer is A

Explanation

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