A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

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HESI 799 RN Exit Exam Capstone Questions

Question 1 of 5

A client is admitted for first and second-degree burns on the face, neck, anterior chest, and hands. The nurse's priority should be

Correct Answer: B

Rationale: Assessing for dyspnea or stridor is crucial as these are signs of airway compromise, which is a priority concern in burns involving the face. Burns on the face can lead to airway swelling or compromise due to airway proximity, making respiratory assessment the top priority. Covering the areas with dry sterile dressings, initiating intravenous therapy, and administering pain medication are important interventions but assessing for airway issues takes precedence in this situation.

Question 2 of 5

An antibiotic IM injection for a 2-year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to

Correct Answer: A

Rationale: Injections over 1 mL should be split into two separate injections for young children. This helps in preventing discomfort, ensuring proper absorption, and reducing the risk of tissue damage. Giving the medication in one injection of 2.0 ml might be too much for a 2-year-old child. Choices B and D are incorrect because the dorsal gluteal site is not recommended for children due to potential injury, and changing the form of medication might not be necessary if the volume can be adjusted. Choice C is unnecessary as splitting the dose into two injections is the appropriate action.

Question 3 of 5

The nurse has given discharge instructions to parents of a child on phenytoin (Dilantin). Which of the following statements suggests that the teaching was effective?

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Question 4 of 5

A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

Correct Answer: A

Rationale: In a post-tonsillectomy and adenoidectomy patient, frequent swallowing is a crucial assessment that requires immediate attention by the nurse. Frequent swallowing can indicate bleeding, a complication that needs urgent intervention. Coughing may be expected due to irritation from the surgery but is not as concerning as potential bleeding. Slow breathing and tachycardia are not typically immediate concerns following this type of surgery.

Question 5 of 5

Which of these findings should the nurse report immediately after a client has a liver biopsy?

Correct Answer: D

Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.

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