A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Draw blood for a complete blood cell (CBC) count.
Inspect the mouth for signs of inhalation injuries.
Administer intravenous pain medication.
Insert an indwelling urinary catheter.
The Correct Answer is B
A. Draw blood for a CBC: Important, but not the priority.
B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.
C. Administer intravenous pain medication: Important, but airway always comes first.
D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.
B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.
C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.
D. Administer pain medication: Pain management is important but not the priority in acute bleeding.
Correct Answer is ["A","B","E"]
Explanation
A. Raisins: Dried fruits like raisins are concentrated sources of potassium and should be avoided in CKD.
B. Bananas: Bananas are high in potassium and commonly restricted in CKD to prevent hyperkalemia.
C. Green beans: Green beans are relatively low in potassium and generally safe for a renal diet.
D. Asparagus: Asparagus has moderate potassium levels but can be included in moderation depending on the client's labs.
E. Tomatoes: Tomatoes, especially in processed forms like sauce or juice, are high in potassium.
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