Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

Assessing for rhinorrhea or otorrhea

Monitoring for changes in the client's baseline focused assessment

Documenting the relevant information in the client's medical record

Range of motion (ROM) of the restrained extremity

Answer and Explanation

The Correct Answer is B

A. Assessing for rhinorrhea or otorrhea:
Relevant in head trauma or skull fracture, not a priority in impaired mobility related to burns.

B. Monitoring for changes in the client's baseline focused assessment:
Changes in perfusion, sensation, and mobility may indicate compartment syndrome or pressure injuries and need prompt attention.

C. Documenting the relevant information in the client's medical record:
Important for continuity of care, but not the priority assessment.

D. Range of motion (ROM) of the restrained extremity:
Helpful to prevent contractures, but monitoring for clinical deterioration takes precedence.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Administering pain medication
Pain control is important but secondary to ensuring the airway is clear.

B. Providing emotional support to the client
While necessary, emotional support is not an immediate priority during the acute phase of burn care.

C. Applying a topical burn ointment
This is appropriate after stabilization, not before airway and breathing are assessed.

D. Assessing the client's airway and breathing
Airway and breathing take top priority in burn clients, especially if the burns involve the face, neck, or chest. Inhalation injury, edema, or airway obstruction can be life-threatening and must be assessed immediately.

A. Change the IV fluid to dextrose and water. B. Discontinue the IV fluid infusion. C. Increase the amount of IV fluid administered per hour. D. Decrease the amount of IV fluid administered per hour.

Correct Answer is C

Explanation

A. Change the IV fluid to dextrose and water:
Hypotonic solutions like D5W are not used in early burn resuscitation. They worsen edema and are not effective for volume expansion.

B. Discontinue the IV fluid infusion:
The patient shows signs of hypovolemic shock and urgently needs more fluid, not less.

C. Increase the amount of IV fluid administered per hour:
The patient has hypotension, tachycardia, and oliguria, indicating inadequate perfusion and fluid resuscitation. The appropriate response is to increase IV fluids per burn resuscitation protocols (e.g., Parkland formula).

D. Decrease the amount of IV fluid administered per hour:
Would worsen hypoperfusion and is contraindicated based on the client's vital signs.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When prioritizing the care of a client with burns, which intervention should the nurse implement first?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

The nurse is explaining to a family the benefit of a patient-controlled analgesia pump. Which of the following is an appropriate use of Dilaudid PCA for burn patients?

A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Which instructions should the nurse provide to the patient being treated with scabies?

The nurse is taking care of a burn patient with deep partial-thickness burns. Which of the following factors can contribute to fluid imbalance in burn patients?

A nurse is assisting with the care of a client who sustained severe carbon monoxide (CO) poisoning after being trapped in a burning building. Which of the following actions should the nurse take first?

Which of the following nursing interventions is appropriate for a client with malignant melanoma?

A patient is brought to the emergency department after a house fire. the patient has extensive trunk and lower extremity burns and is diagnosed with a full thickness burn. What assessment findings does the nurse expect?