A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Insert an indwelling urinary catheter.

Draw blood for a complete blood cell (CBC) count.

Inspect the mouth for signs of inhalation injuries.

Administer intravenous pain medication.

Answer and Explanation

The Correct Answer is C

This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.

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Correct Answer is D

Explanation

The correct answer is choiceD. Fresh flowers and potted plants in the room.

Choice A rationale:

While activities that could result in bleeding should be avoided in patients with low platelet counts, this is not directly related to neutropenia.Neutropenia primarily increases the risk of infection rather than bleeding.

Choice B rationale:

Restricting oral fluid intake to between meals is not relevant to managing neutropenia.Adequate hydration is important, but the timing of fluid intake does not impact neutropenia management.

Choice C rationale:

While limiting visitors can help reduce the risk of infection, it is not necessary to restrict all visitors.Instead, visitors should follow strict hygiene practices, such as handwashing and wearing masks, to minimize infection risk.

Choice D rationale:

Fresh flowers and potted plants can harbor bacteria and fungi, which pose a significant infection risk to neutropenic patients.Therefore, these should be avoided in the patient’s room.

A. WBC 5,000/mm3 B. Platelets 150,000/mm3 C. Positive Western blot test D. CD4-T-cell count 180 cells/mm3

Correct Answer is D

Explanation

CD4-T-cell count 180 cells/mm3 is the nurse's priority. Rationale: This is because a low CD4-T-cell count indicates a high risk of opportunistic infections and impaired immune function. The nurse should implement infection prevention measures and monitor the client for signs of infection. The other values are not as critical as the CD4-T-cell count.

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A nurse in an emergency room is caring a the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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