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

Initial management of a client with partial-thickness burns to the upper torso requires rapid assessment of airway and breathing because thermal injuries can compromise ventilation, especially when burns involve the chest and may cause airway edema or impaired chest expansion. Burn injury triggers a systemic inflammatory response that can also affect oxygenation and perfusion. Priority nursing care follows ABC principles, with immediate focus on ensuring adequate oxygen delivery and early detection of respiratory compromise.

Rationale:
A. Using aseptic technique during wound care is important for preventing infection in a client with partial-thickness burns, but it is not the priority action on initial admission. Infection control measures are essential later during ongoing wound management, once airway and breathing stability are confirmed. Immediate life-threatening concerns take precedence over wound care procedures.

B. Obtaining oxygen saturation is the priority because upper torso burns can lead to inhalation injury, airway edema, or restricted chest wall movement. Monitoring oxygenation provides immediate information about respiratory status and helps detect early hypoxia. In burn care, ensuring adequate ventilation and oxygen delivery is the first step in stabilizing the client following Burn injury.

C. Checking the WBC count is useful for monitoring infection or inflammatory response, but it is not an immediate priority during initial burn assessment. Laboratory values do not provide real-time information about airway patency or oxygenation. Priority must remain on rapid physiologic stabilization rather than diagnostic review.

D. Regulating IV fluids is an important aspect of burn management to maintain perfusion and prevent hypovolemic shock, but it is secondary to immediate assessment of airway and breathing. Fluid resuscitation is guided after initial stabilization and ongoing monitoring of vital organ function. Oxygenation and respiratory status must be addressed first.

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Correct Answer is D

Explanation

Recognition of medication allergies is essential when caring for clients reporting hypersensitivity to antibiotics such as penicillin. True allergic reactions involve an immune-mediated response that can range from mild skin manifestations to life-threatening airway compromise. Penicillin allergy reactions are typically mediated by IgE antibodies and can progress rapidly after exposure. Nurses must distinguish allergic responses from common adverse effects such as gastrointestinal upset or nonspecific symptoms.

Rationale:
A. Nausea is a common non-allergic side effect of antibiotics and does not indicate an immune-mediated hypersensitivity reaction. It is related to gastrointestinal irritation or altered gut flora rather than antibody activation. Therefore, it is not considered a sign of penicillin allergy.

B. Diarrhea is also a frequent adverse effect of antibiotic therapy due to disruption of normal intestinal microbiota. While it may indicate conditions like antibiotic-associated colitis, it is not specific for an allergic reaction. It does not involve histamine release or immune-mediated hypersensitivity.

C. Insomnia is not associated with penicillin allergy and does not reflect an immune response. Sleep disturbances may occur due to illness, hospitalization, or anxiety, but they are unrelated to drug hypersensitivity mechanisms. Therefore, it is not a relevant indicator of allergic reaction.

D. Angioedema is a serious manifestation of an allergic reaction to Penicillin and involves rapid swelling of subcutaneous tissues, often affecting the face, lips, tongue, and airway. It results from histamine-mediated vascular permeability and can progress to airway obstruction. This is a true sign of anaphylactic-type hypersensitivity requiring immediate intervention.

A. Providing postmortem care to a client B. Changing a sterile dressing for a client who is postoperative C. Performing a gastrostomy feeding on a stable client D. Observing the patency of an intravenous catheter on a stable client

Correct Answer is A

Explanation

Delegation in nursing requires assigning tasks based on the Five Rights of Delegation, ensuring patient safety, task complexity, and the skill level of assistive personnel (AP). APs are trained to perform routine, non-invasive, and standardized care activities for stable clients. The nurse retains responsibility for assessment, evaluation, sterile procedures, and clinical judgment. Postmortem care is a task that is standardized, does not require clinical decision-making, and is appropriate for delegation in most care settings.

Rationale:
A. Providing postmortem care is appropriate for delegation to assistive personnel because it involves routine physical care of the deceased body, including bathing, positioning, and preparing the body for family viewing. It does not require assessment, sterile technique, or clinical judgment. The task is structured and can be safely performed by trained APs under nurse supervision.

B. Changing a sterile dressing for a postoperative client is not appropriate for delegation because it requires sterile technique, assessment of the wound, and evaluation for infection or healing progression. These actions require licensed nursing judgment to identify complications such as drainage, dehiscence, or infection. Therefore, it must be performed by a licensed nurse.

C. Performing a gastrostomy feeding, even in a stable client, is generally not delegated to APs because it involves risk for aspiration, tube placement verification considerations, and monitoring for tolerance. Although some settings may allow AP involvement in feeding under specific protocols, initial and ongoing assessment of tube patency and client response requires nursing judgment.

D. Observing patency of an intravenous catheter is a nursing responsibility because it requires assessment of infusion site condition, evaluation for infiltration or phlebitis, and clinical decision-making regarding continuation or discontinuation of therapy. APs are not trained or authorized to assess IV lines or detect complications that require intervention.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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