A nurse in an emergency room is caring a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Insert an indwelling urinary catheter.
Draw blood for a complete blood cell (CBC) count.
Administer intravenous pain medication.
Inspect the mouth for signs of inhalation injuries
The Correct Answer is D
A. Inserting a urinary catheter is important for monitoring fluid status but is not the immediate priority.
B. Drawing blood for labs is necessary but not the first concern in a potentially life-threatening situation.
C. Pain management is important, but airway assessment takes precedence.
D. Inspecting the mouth for signs of inhalation injury is the priority because facial burns increase the risk of airway compromise. Airway management is the first priority in emergency burn care to prevent respiratory failure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. The Rule of Nines is the most commonly used and appropriate method to quickly estimate the TBSA burned in adult patients. It divides the body into sections, each representing approximately 9% (or a multiple thereof) of the total body surface area.
B. BMI is used to assess body fat and weight status, not burn area.
C. The patient’s palm size is roughly 1% of TBSA and is more commonly used for estimating small, scattered burns, not for calculating large surface areas.
D. There is no such tool as the "Parkland Burn Chart"; the Parkland Formula is used for fluid resuscitation after TBSA is estimated.
Correct Answer is B
Explanation
A. Elevated heart rate may indicate stress or early hypovolemia but is less urgent than airway concerns.
B. Difficulty swallowing suggests possible airway edema or inhalation injury, which can rapidly progress and compromise the airway—this is the highest priority.
C. Urinary output of 25 mL/hr is low (less than 0.5 mL/kg/hr in most adults) and concerning, but airway issues take precedence.
D. Pain is important to manage but is not immediately life-threatening compared to airway compromise.
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