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 D
Explanation
Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.
Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.
Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.
Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.
Correct Answer is ["A","C","E"]
Explanation
Choice A reason: Checking and documenting the client's vital signs is a correct action, because it provides a baseline for comparison and helps to monitor for any signs of adverse reactions to the transfusion.
Choice B reason: Ensuring that the client's IV site uses a 22-gauge needle is an incorrect action, because a larger gauge needle (18- or 20-gauge) is preferred for blood transfusions to prevent hemolysis of the RBCs.
Choice C reason: Verifying that the blood type and Rh of the packed RBCs are checked by two nurses is a correct action, because it is a standard safety procedure to prevent transfusion errors and ensure compatibility.
Choice D reason: Obtaining a bag of lactated Ringer's IV solution is an incorrect action, because only normal saline (0.9% sodium chloride) should be used as the IV solution for blood transfusions. Other solutions may cause hemolysis or clotting of the blood.
Choice E reason: Providing the RN with tubing that has a filter is a correct action, because a filter is required for blood transfusions to remove any clumps or debris from the blood.
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