NCLEX-PN

Category - Physiological Adaptation

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A client is admitted to the burn unit after sustaining partial thickness burns in the neck area. The nurse assigned to monitor the client prioritizes which physical assessment?

Replacement of the lost fluids
Urinary output per hour
Body heat conservation
Circumference of the neck

Explanation

Answer: D - The priority of the nurse is to monitor the circumference changes of the neck. Burns involving the neck area increase the client’s risk for airway edema, which may cause airway obstruction, if not detected or managed early.

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