Ati nur211 mobility exam
Ati nur211 mobility exam ( 29 Questions)
A nurse is caring for a client with burns on the face, ears, and eyelids. Which of the following findings should the nurse prioritize reporting to the provider?
Difficulty swallowing is a critical finding in a client with burns to the face, ears, and eyelids. This symptom can indicate airway edema or obstruction, which is a life-threatening condition. Burns in these areas can cause significant swelling, leading to compromised airways. Immediate intervention is required to secure the airway and prevent respiratory failure.
Pain of 6 on a scale of 0 to 10 is important to manage for patient comfort and to prevent complications related to pain, such as increased heart rate and blood pressure. However, it is not the immediate priority over potential airway compromise. Pain management can be addressed once the airway is secured.
A heart rate of 122/min indicates tachycardia, which can be a response to pain, stress, or hypovolemia. While it is important to monitor and manage, it is not as immediately life-threatening as airway obstruction. Tachycardia can be addressed after ensuring the airway is clear.
Urinary output of 25 mL/hr is below the normal range (typically 30-50 mL/hr) and can indicate dehydration or renal impairment. While this is a concerning finding, it is not the immediate priority compared to securing the airway. Fluid resuscitation and renal function can be managed once the airway is stabilized.
Choice A Reason:
Difficulty swallowing is a critical finding in a client with burns to the face, ears, and eyelids. This symptom can indicate airway edema or obstruction, which is a life-threatening condition. Burns in these areas can cause significant swelling, leading to compromised airways. Immediate intervention is required to secure the airway and prevent respiratory failure.
Choice B Reason:
Pain of 6 on a scale of 0 to 10 is important to manage for patient comfort and to prevent complications related to pain, such as increased heart rate and blood pressure. However, it is not the immediate priority over potential airway compromise. Pain management can be addressed once the airway is secured.
Choice C Reason:
A heart rate of 122/min indicates tachycardia, which can be a response to pain, stress, or hypovolemia. While it is important to monitor and manage, it is not as immediately life-threatening as airway obstruction. Tachycardia can be addressed after ensuring the airway is clear.
Choice D Reason:
Urinary output of 25 mL/hr is below the normal range (typically 30-50 mL/hr) and can indicate dehydration or renal impairment. While this is a concerning finding, it is not the immediate priority compared to securing the airway. Fluid resuscitation and renal function can be managed once the airway is stabilized.