A nurse in an urgent care clinic is collecting data from a client who has extensive burns, including on her face. Which of the following data should the nurse collect first?
Estimation of burn injury
Respiratory rate
Presence of bowel sounds
Level of pain
The Correct Answer is B
Choice A reason: This is an important data, but not the first one. The nurse should first assess the client's airway, breathing, and circulation, which are the priorities in any emergency situation.
Choice B reason: This is the correct data, because the nurse should first collect the respiratory rate to determine if the client has any signs of airway obstruction, inhalation injury, or respiratory distress, which are life-threatening complications of facial burns.
Choice C reason: This is a relevant data, but not the first one. The nurse should collect the presence of bowel sounds later, after ensuring the client's airway, breathing, and circulation are stable, to assess the client's gastrointestinal function and possible paralytic ileus.
Choice D reason: This is a significant data, but not the first one. The nurse should collect the level of pain later, after ensuring the client's airway, breathing, and circulation are stable, to provide adequate analgesia and comfort measures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is a correct statement, because using a soft toothbrush or foam swab for oral care can help prevent trauma and irritation to the mucous membranes of the mouth, which are inflamed and ulcerated due to stomatitis. The client should brush the teeth gently and avoid using dental floss.
Choice B reason: This is an incorrect statement, because using an alcohol-based mouthwash can cause burning, drying, and further damage to the mucous membranes of the mouth, which are already compromised by stomatitis. The client should avoid using any mouthwash that contains alcohol, menthol, or other harsh ingredients.
Choice C reason: This is a correct statement, because using a straw when drinking liquids can help reduce the contact and friction of the fluids with the mouth sores, which can cause pain and discomfort. The client should drink plenty of fluids to prevent dehydration and maintain hydration.
Choice D reason: This is a correct statement, because rinsing the mouth frequently with a hydrogen peroxide solution can help cleanse and disinfect the mouth, and promote healing of the mouth sores. The client should dilute the hydrogen peroxide with water and rinse the mouth at least four times a day, or as prescribed by the provider.
Correct Answer is A
Explanation
Choice A reason: This is a correct statement, because checking the heart rate each day can help monitor the function and effectiveness of the pacemaker, and detect any signs of malfunction, such as bradycardia, tachycardia, or irregular rhythm.
Choice B reason: This is an incorrect statement, because the client still needs to take the antihypertensive medications as prescribed, even with a pacemaker. The pacemaker regulates the heart rate, but does not control the blood pressure, which can be affected by other factors, such as stress, diet, or kidney function.
Choice C reason: This is an incorrect statement, because the client should avoid stretching the arms above the head for the first few weeks after the pacemaker insertion, as it can cause dislodgment or damage to the pacemaker leads. The client should limit the arm movements and activities until the incision site heals and the provider approves.
Choice D reason: This is an incorrect statement, because the client can stand in front of a microwave oven without any risk, as long as the oven is in good working condition and does not leak radiation. The modern microwave ovens and pacemakers are designed to prevent any interference or damage. However, the client should avoid close contact with other sources of electromagnetic fields, such as metal detectors, cell phones, or MRI machines.
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