The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Administer morphine 5 mg intravenously.

Administer a tetanus immunization.

Assist the client to cough and deep breathe.

Listen to breath sounds.

Answer and Explanation

The Correct Answer is D

Choice A reason: Morphine for pain is important but secondary to assessing airway and breathing in burns, as chest involvement risks respiratory compromise. Listening to breath sounds ensures stability, making this incorrect, as it’s less urgent than the nurse’s priority of respiratory assessment.

Choice B reason: Tetanus immunization prevents infection but is not urgent in acute burn management. Breath sounds assess respiratory status, critical with chest burns, making this incorrect, as it’s secondary to the nurse’s first action of ensuring airway and breathing stability.

Choice C reason: Coughing and deep breathing support respiratory function but assume stable breathing. Listening to breath sounds confirms airway patency in chest burns, making this incorrect, as it’s less immediate than the nurse’s priority of assessing respiratory status first.

Choice D reason: Listening to breath sounds is the first action to assess for respiratory compromise in deep partial thickness chest burns, as restlessness may indicate hypoxia. This aligns with burn care priorities, making it the correct action for the nurse to take initially.

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Correct Answer is D

Explanation

Choice A reason: Hypertension and tachycardia may occur in dialysis but aren’t specific to disequilibrium syndrome, which causes neurological symptoms. Headache and twitching are key, making this incorrect, as it’s less precise than the nurse’s expected manifestations of disequilibrium syndrome.

Choice B reason: Hypotension may occur in dialysis, but bradycardia and hypothermia aren’t typical of disequilibrium syndrome, which affects the brain. Deteriorating consciousness is correct, making this incorrect, as it doesn’t align with the nurse’s assessment for this complication.

Choice C reason: Restlessness and weakness are vague and less specific than headache and twitching, which indicate cerebral edema in disequilibrium syndrome. This is incorrect, as it’s not the primary manifestation the nurse would assess in the dialysis client.

Choice D reason: Headache, deteriorating consciousness, and twitching indicate disequilibrium syndrome due to rapid osmotic shifts during hemodialysis. This aligns with neurological assessment, making it the correct set of manifestations the nurse would monitor in the client at risk.

A. Apply supplemental oxygen via nasal cannula. B. Administer intravenous morphine for pain. C. Keep the hard collar in place until cleared. D. Administer intravenous methylprednisolone (Solu-Medrol) as prescribed.

Correct Answer is C

Explanation

Choice A reason: Supplemental oxygen is unnecessary with a normal respiratory rate (16) and stable vitals. Maintaining the collar prevents spinal injury, making this incorrect, as it’s not indicated compared to the nurse’s priority of ensuring spinal stability in a client with a fall history.

Choice B reason: Morphine for pain is premature without confirming spinal stability, as it may mask symptoms. Keeping the collar in place is critical, making this incorrect, as it risks missing neurological changes in the nurse’s care of a potential spinal injury client.

Choice C reason: Keeping the hard collar in place until cleared by imaging prevents worsening of potential spinal injury after a trampoline fall. This aligns with trauma care protocols, making it the correct action for the nurse to take to ensure the client’s safety and stability.

Choice D reason: Methylprednisolone is used for confirmed spinal cord injury, not suspected cases without imaging. Maintaining the collar is the priority, making this incorrect, as it’s premature compared to the nurse’s focus on spinal precautions in a client with numbness and tingling.

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The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

Correct Answer is C

Explanation

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