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
B. Pulmonary artery catheters typically have multiple lumens that allow for IV access and medication administration.
C. Some pulmonary artery catheters have an atrial sensing electrode to monitor atrial activity.
D. Pulmonary artery catheters can provide continuous cardiac output monitoring using thermodilution or other methods.
A. Therefore, all these features are specialized aspects of pulmonary artery pressure monitoring.
Correct Answer is B
Explanation
A. If the pilot balloon is inflated, the cuff cannot be deflated.
B. The pilot balloon is connected to the cuff; when the pilot balloon is inflated, it indicates that the cuff inside the trachea or airway is also inflated, providing a seal.
C. Partial inflation cannot be determined solely by the pilot balloon’s inflation status.
D. The pilot balloon is directly related to the cuff and serves as an indicator of its inflation status.
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