A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

Use aseptic technique during wound care for the client.

Obtain the client's oxygen saturation levels.

Check the client's WBC count.

Regulate IV fluids to maintain the client's urinary output.

Answer and Explanation

The Correct Answer is B

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.

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Correct Answer is B

Explanation

A. Evaluate the need for the client to remain in mitten restraints. Assessing the necessity of restraints is a nursing responsibility that requires clinical judgment. Nurses must evaluate the client's condition and determine if restraints can be discontinued or if alternative measures are appropriate.
B. Assist the client with range-of-motion exercises of the hands. Assistive personnel (AP) can perform tasks that promote mobility, such as passive or active range-of-motion exercises. These exercises help prevent stiffness and maintain circulation in restrained extremities.
C. Determine the circulation status of the affected extremities every 2 hr. Assessing circulation involves evaluating capillary refill, skin color, temperature, and sensation, which requires nursing assessment skills. This task should be performed by a nurse rather than delegated to an AP.
D. Instruct the client's family about the purpose of mitten restraints. Educating the family on medical interventions falls within the nurse’s scope of practice. The nurse must explain the rationale, risks, and alternatives to ensure family members understand the need for restraints.

A. Ensure that the client gave informed consent. B. Administer an oral contrast solution. C. Ensure that the client's bladder is full. D. Inform the client the procedure will take 60 min.

Correct Answer is A

Explanation

A. Ensure that the client gave informed consent. Confirming that the client has provided informed consent is a critical step before any invasive procedure, including an esophagogastroduodenoscopy (EGD). The nurse should ensure that the client understands the procedure, its risks, benefits, and any alternatives before the procedure begins.
B. Administer an oral contrast solution. Oral contrast is typically not used for an EGD, as the procedure involves direct visualization of the esophagus, stomach, and duodenum. Instead, the client may need to follow specific dietary restrictions prior to the procedure, such as fasting.
C. Ensure that the client's bladder is full. A full bladder is not required for an EGD. In fact, it is more important for the client to be in a comfortable position and relaxed during the procedure. An empty stomach is preferred to reduce the risk of aspiration.
D. Inform the client the procedure will take 60 min. While informing the client about the duration of the procedure is important, the exact time can vary. Providing a range or informing the client that the procedure may take some time is more appropriate, as it helps manage expectations without causing unnecessary anxiety.

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A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

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