You have just received change-of-shift report for the burn unit. Which client should you assess first?

Correct Answer: B

Rationale: In this scenario, the correct answer is option B - the client who has just arrived from the emergency department with facial burns associated with a house fire. This client should be assessed first because facial burns can compromise the airway and breathing, posing an immediate threat to life. As a nurse, ensuring adequate airway, breathing, and circulation (ABCs) is a top priority in emergency situations. Option A may seem urgent due to the severe leg pain, but deep partial-thickness burns do not immediately jeopardize airway or breathing. Option C, while important, involves a client who has already received treatment and is not currently in an acute life-threatening situation. Option D, the client waiting for discharge teaching, is the least urgent as their condition has been stable for weeks. Educationally, this question highlights the critical thinking needed in prioritizing care based on the acuity of the situation. Understanding the immediate threats posed by certain conditions, such as facial burns and potential airway compromise, is crucial for nurses working in emergency or critical care settings. It reinforces the importance of ABC assessments and quick decision-making in prioritizing care to ensure the best outcomes for patients.

Correct Answer: C

Rationale: In this scenario, option C, "The client complains of epigastric pain," is the most concerning information. Prednisone, a corticosteroid, can cause gastrointestinal side effects such as peptic ulcers, gastritis, and pancreatitis, which may present as epigastric pain. This symptom could indicate a serious adverse effect of the medication that requires immediate attention to prevent complications. Option A, "The client's blood glucose is 136 mg/dL," is less concerning because a blood glucose level of 136 mg/dL is within the normal range and is not typically associated with prednisone use at that dose. Option B, "The client states, 'I am eating all the time,'" may be a side effect of prednisone, known as increased appetite or weight gain, but it is a common and expected side effect rather than a sign of a serious adverse effect. Option D, "The client's blood pressure is 148/84," while elevated, is not directly related to the adverse effects of prednisone and is also not as immediately concerning as the symptom of epigastric pain, which could indicate a potentially serious complication. Educationally, understanding the potential adverse effects of medications is crucial for nurses to provide safe and effective care to their patients. Recognizing and prioritizing concerning symptoms can help prevent further complications and ensure timely intervention. It is essential for healthcare providers to monitor patients closely for adverse effects of medications and promptly address any concerning symptoms to optimize patient outcomes.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Long-standing cardiopulmonary disease. When the angle between the nail base and the skin, known as the Lovibond angle, exceeds 160°, it is called "clubbing." Clubbing of the nails is a clinical sign associated with various underlying medical conditions, with long-standing cardiopulmonary diseases being a significant cause. In cardiopulmonary diseases like chronic obstructive pulmonary disease (COPD) or congenital heart defects, clubbing occurs due to chronic hypoxia and tissue hypoxia, leading to changes in the nail bed vasculature and connective tissue. Option A) Poor circulation is not the most likely cause in this scenario because clubbing specifically points towards chronic conditions affecting the heart and lungs rather than just poor circulation alone. Option B) Iron deficiency anemia is also not the correct answer in this case, as it is not typically associated with the physical presentation of clubbing. Iron deficiency anemia can manifest with other nail changes like koilonychia (spoon-shaped nails) but not clubbing. Option D) Fungal infection is an incorrect choice as well because fungal infections of the nails typically present with changes in nail color, texture, and thickness, rather than altering the angle between the nail base and skin. Educational context: Understanding physical assessment findings like nail clubbing is crucial for healthcare professionals, especially nurses, as it can provide valuable clues to an underlying systemic condition. Recognizing clubbing early can prompt further investigations and timely interventions for conditions like cardiopulmonary diseases. This knowledge enhances the nurse's ability to monitor patients effectively, collaborate with the healthcare team, and provide holistic care.

Correct Answer: A

Rationale: Educational Rationale: The correct answer is A) A thorough washing of the hands. Benzoyl peroxide, commonly used in acne preparations, is a bleaching agent that can cause fabric discoloration upon contact. Instructing the client to thoroughly wash their hands after applying the medication is essential to prevent the transfer of benzoyl peroxide to clothing or other fabrics, thereby reducing the risk of discoloration. Option B) A thorough bath after the medication is incorrect because the primary concern is preventing the transfer of benzoyl peroxide to fabrics, which can be effectively addressed by washing the hands only. Option C) Wear disposable clothes is not necessary if the client follows proper hand hygiene practices as instructed in Option A. Option D) Wear disposable plastic gloves is excessive for the application of acne preparations containing benzoyl peroxide. It is more practical and sufficient for the client to wash their hands thoroughly after application. Educational Context: Understanding the side effects and proper handling of medications is crucial for both healthcare providers and patients. In the case of benzoyl peroxide, awareness of its bleaching properties and the necessary precautions can prevent unintended fabric discoloration. This question highlights the importance of patient education regarding the safe use of topical medications and the simple yet effective measures that can be taken to mitigate potential issues.

Correct Answer: B

Rationale: The correct answer is B) Apply sunscreen with a high SPF when outdoors. This instruction is important because UV radiation can cause hyperpigmentation of the newly healed skin, leading to increased scarring. Sunscreen helps protect the delicate new skin from harmful UV rays, which is crucial for optimal healing and scar prevention. Option A) Wear thick clothes is incorrect because while clothing can offer some protection from the sun, it is not as effective as sunscreen in providing broad-spectrum protection. Also, thick clothing may not be comfortable or practical for the client. Option C) Avoid use of topical gels is incorrect because certain topical gels, especially those prescribed by healthcare providers, can aid in wound healing and scar prevention. Avoiding them completely may hinder the healing process. Option D) Avoid cold water baths is incorrect because cold water can actually help soothe the skin and reduce inflammation following skin grafting. However, prolonged exposure to cold water or extreme temperatures should be avoided. In an educational context, understanding the importance of proper post-burn care is essential for nurses and healthcare providers. Providing accurate instructions to clients post-skin grafting can significantly impact their healing outcomes and overall well-being. It is vital to educate clients on best practices to minimize scarring and promote optimal healing after such procedures.