A nurse in an emergency room is caring a the 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.
Inspect the mouth for signs of inhalation injuries.
Administer intravenous pain medication.
The Correct Answer is C
This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because Western blot analysis detects specific antibodies to HIV antigens and has a high specificity and sensitivity for HIV infection. CD4+ T-cell count measures the number of helper T cells in the blood and indicates the degree of immunosuppression in clients with HIV infection, but it does not confirm the diagnosis. Quantitative RNA assay and viral load test measure the amount of HIV RNA in the blood and indicate the level of viral replication and response to antiretroviral therapy, but they do not confirm the diagnosis.
Correct Answer is A
Explanation
This is because aspirin can cause salicylate toxicity, which can manifest as tinnitus, hearing loss, vertigo, headache, confusion, and hyperventilation. The nurse should monitor the client's serum salicylate level and advise the client to report any signs of toxicity to the provider.
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