Nokea
The client is being admitted to the ED after a house fire. Place the client's problems in the order of priority in which they should be addressed by the nurse.
- A. Has 48% partial- and full-thickness burn injury
- B. Laceration on the face that has stopped bleeding
- C. Inhalation injury from smoke
- D. History of hypertension
Correct Answer: C,A,B,D
Rationale: Inhalation injury from smoke is the priority problem that should be addressed first to ensure that the client has a patent airway. The 48% partial- and full-thickness burn injury should be addressed next due to fluid loss and pain. The laceration on the face that has stopped bleeding should be addressed next, possibly requiring suturing. History of hypertension can be addressed last, as fluid shifts from the burn are likely to lower BP.
You may also like to solve these questions
Which health teaching instruction given by the nurse is most important for a client with conjunctivitis?
- A. Eat a well-balanced, nutritious diet with plenty of fluids.
- B. Always wear dark sunglasses when in bright light.
- C. Do not share towels or washcloths with family members.
- D. Avoid all aspirin-containing products.
Correct Answer: C
Rationale: Preventing the spread of conjunctivitis involves avoiding shared items like towels.
Which nursing action is most appropriate at this time?
- A. Obtaining the client's pulse and blood pressure
- B. Monitoring the client for respiratory distress
- C. Identifying the client's next of kin
- D. Determining the extent of the burn
Correct Answer: B
Rationale: Burns to the chest and neck risk airway compromise, requiring respiratory monitoring.
When the client asks about the cause of shingles, the nurse answers correctly with which cause of the disease?
- A. The reactivation of a dormant virus
- B. A vector insect such as a tick
- C. A toxin from a bacterial infection
- D. An antibody response to a drug allergen
Correct Answer: A
Rationale: Shingles results from reactivation of the varicella-zoster virus.
Which comment made to the nurse strongly suggests that the client with glaucoma needs more teaching?
- A. I must wash my hands before instilling the dress.
- B. This drug decreases the formation of fluid in my eye.
- C. I'll need to take this until my eye pressure is normal.
- D. The cap on the container should be replaced after use.
Correct Answer: C
Rationale: Glaucoma requires lifelong treatment, not just until pressure normalizes.
Which client physiological outcome (goal) is appropriate for a client diagnosed with skin cancer who has had surgery to remove the lesion?
- A. The client will express feelings of fear.
- B. The client will ask questions about the diagnosis.
- C. The client will state a diminished level of pain.
- D. The client will demonstrate care of the operative site.
Correct Answer: D
Rationale: Demonstrating operative site care ensures healing and prevents infection, a physiological outcome. Fear, questions, and pain are psychosocial or secondary.