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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
- Administer sublingual nitroglycerin. Nitroglycerin is a first-line treatment for angina or suspected myocardial infarction. It dilates coronary arteries, improving blood flow and reducing myocardial oxygen demand.
- Apply supplemental oxygen. Routine oxygen administration is no longer recommended unless the client is hypoxic (oxygen saturation below 90%) because excessive oxygen can lead to vasoconstriction and worsen myocardial injury.
- Obtain a 12-lead ECG. While an ECG is important for diagnosing myocardial infarction, the priority in an acute chest pain episode is symptom relief and hemodynamic stability. The ECG should already have been obtained at admission.
- Administer morphine sulfate IV. Morphine is used to manage severe chest pain that is not relieved by nitroglycerin. It reduces myocardial oxygen demand, preload, and anxiety, which can help relieve symptoms.
- Monitor vital signs. Continuous monitoring is essential, but it is not the most immediate intervention in an acute episode of worsening chest pain. The focus should be on relieving ischemia and reducing myocardial workload.
- Educate the client about smoking cessation. While smoking cessation is critical for long-term cardiovascular health, education is not a priority when the client is experiencing acute chest pain requiring immediate intervention.
Correct Answer is B
Explanation
A. "Sit on the edge of the bed while I tap your knee." The patellar reflex, also known as the knee-jerk reflex, is tested by tapping the patellar tendon while the client’s leg dangles. This does not assess the Babinski reflex, which involves stroking the sole of the foot.
B. "Lie down and I will stroke the bottom of your foot." The Babinski reflex is tested by stroking the lateral aspect of the sole from heel to toe. A normal response in adults is toe flexion, while dorsiflexion of the great toe with fanning of the others is abnormal and indicates neurological dysfunction.
C. "Place your foot in my hand and I will tap the back of your heel." This describes testing for the Achilles tendon reflex, which assesses the function of the S1 spinal nerve. The Babinski reflex requires a stroking motion along the foot’s sole rather than tapping the heel.
D. "Relax your arm across your chest and I will test your elbow extension." This describes testing the triceps reflex, which assesses the function of the C6-C7 nerve roots. The Babinski reflex is specific to neurological assessment of the lower extremities.
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