A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

Obtain a blood specimen for ABG analysis.

Apply 100% humidified oxygen.

Obtain a baseline ECG.

Insert an 18-gauge IV catheter.

Answer and Explanation

The Correct Answer is B

A. Obtain a blood specimen for ABG analysis. Important, but not the first action.

B.   In a client with burn injuries experiencing signs of airway compromise (drooling, hoarseness), the first action should be to ensure adequate oxygenation. Applying 100% humidified oxygen can help manage potential airway edema.
C.   Obtain a baseline ECG. Necessary for monitoring but secondary to securing the airway.
D.   Insert an 18-gauge IV catheter. Essential for fluid resuscitation and medication administration, but after ensuring adequate oxygenation.

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Correct Answer is C

Explanation

A: This response invalidates the client's experience and may cause them to feel misunderstood or alienated.
B: This response does not address the seriousness of the client's statement and dismisses their fear.
C: This is an appropriate response because it acknowledges the client's experience without agreeing with the delusion, helping to maintain a grasp on reality.
D: While this question could be useful during a more in-depth conversation, it does not address the immediate safety concern and may not help deescalate the situation.

A. Inform the client that the transfusion is mandatory. B. Notify risk management about the client's refusal. C. Document the client's refusal in the medical record. D. Suggest that the client explore alternative therapies.

Correct Answer is C

Explanation

A. Informing the client that the transfusion is mandatory disregards the client's autonomy and right to refuse treatment.
B. While documenting the client's refusal is important, notifying risk management about the refusal is not necessary unless there are specific facility policies or legal requirements.
C. Documenting the client's refusal in the medical record ensures that the refusal is properly recorded and communicated to the healthcare team, protecting both the client's autonomy and the healthcare provider.
D. While it's important to respect the client's autonomy, suggesting alternative therapies may not be appropriate in this context and could undermine the client's decision-making process.

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A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?

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