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 B
Explanation
A. Hamburger on a bun and a banana: Bananas are high in potassium, which must be restricted in CKD. Processed hamburger meat may also be high in sodium and phosphorus.
B. Spaghetti and meat sauce with breadsticks: Pasta and meat sauce are generally low in potassium and phosphorus if made without salt substitutes. Breadsticks are low in potassium.
C. Carrots and spinach: Spinach is high in potassium and phosphorus. Cooked carrots are borderline and must be portion-controlled.
D. Cold cuts with bun and fresh pears: Cold cuts are typically high in sodium and phosphorus. Pears are generally acceptable, but the entire meal is unsuitable due to the cold cuts.
Correct Answer is C
Explanation
A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.
B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.
C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.
D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.
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