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 B

Explanation

Choice A reason: Monitoring for further occurrences is passive and doesn’t address the immediate breach of confidentiality. Advising to stop the conversation protects the client, making this incorrect, as it delays the nurse’s priority of halting the unethical discussion promptly.

Choice B reason: Advising the nurses to cease their communication is the first action to stop the breach of client confidentiality in a public setting. This aligns with ethical and privacy standards, making it the correct initial step for the newly licensed RN to take.

Choice C reason: Informing the manager is important but secondary to stopping the conversation to prevent further disclosure. Advising to cease is immediate, making this incorrect, as it’s not the first action the RN should take to address the confidentiality breach.

Choice D reason: Submitting a report follows stopping the conversation and notifying the manager. Advising to cease is the first step, making this incorrect, as it delays the RN’s priority of immediately halting the nurses’ inappropriate discussion about the client.

A. “I have had unprotected sex with multiple partners.” B. “I ate shellfish about 2 weeks ago at a local restaurant.” C. “I was an intravenous drug abuser in the past and shared needles.” D. “I had a blood transfusion 30 years ago after major abdominal surgery.”

Correct Answer is B

Explanation

Choice A reason: Unprotected sex is a risk for hepatitis B or C, not A, which is fecal-oral. Shellfish consumption is a common source, making this incorrect, as it doesn’t support the nurse’s diagnosis of hepatitis A based on the client’s history.

Choice B reason: Eating contaminated shellfish is a common cause of hepatitis A, transmitted via the fecal-oral route, with symptoms appearing 2-6 weeks later. This aligns with the diagnosis, making it the correct statement supporting the client’s hepatitis A diagnosis.

Choice C reason: Sharing needles spreads hepatitis B or C, not A, which is foodborne. Shellfish is a hepatitis A source, making this incorrect, as it’s unrelated to the nurse’s evaluation of the client’s flu-like symptoms and jaundice.

Choice D reason: Blood transfusions before 1992 risked hepatitis C, not A, which is fecal-oral. Eating shellfish supports hepatitis A, making this incorrect, as it doesn’t align with the nurse’s diagnosis based on the client’s jaundice and flu-like symptoms.

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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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