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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This is because Western blot analysis detects specific antibodies to HIV antigens and has a high specificity and sensitivity for HIV infection. CD4+ T-cell count measures the number of helper T cells in the blood and indicates the degree of immunosuppression in clients with HIV infection, but it does not confirm the diagnosis. Quantitative RNA assay and viral load test measure the amount of HIV RNA in the blood and indicate the level of viral replication and response to antiretroviral therapy, but they do not confirm the diagnosis.
Correct Answer is ["A","C","D","E","F"]
Explanation
- Disorientation may indicate hypoxia, infection, or medication side effects. - Yellow sputum may indicate a bacterial infection that requires antibiotics. - Nebulizer use may indicate that the client is not using it correctly or regularly as prescribed, which can affect their lung function and oxygenation. - Ankle edema may indicate fluid overload or heart failure, which can worsen COPD symptoms and increase the risk of complications.
- Living alone may pose safety risks for the client, especially if they are disoriented or have difficulty managing their oxygen and nebulizer treatments. The nurse should assess the client's support system and refer them to community resources if needed.
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