A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Draw blood for a complete blood cell (CBC) count.
Inspect the mouth for signs of inhalation injuries.
Administer intravenous pain medication.
Insert an indwelling urinary catheter.
The Correct Answer is B
A. Draw blood for a CBC: Important, but not the priority.
B. Inspect the mouth for signs of inhalation injuries: Airway assessment is always the priority in facial/chest burns due to the risk of inhalation injury and impending airway compromise.
C. Administer intravenous pain medication: Important, but airway always comes first.
D. Insert an indwelling urinary catheter: Urine output monitoring is important for fluid resuscitation but follows airway stabilization.
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Related Questions
Correct Answer is C
Explanation
A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.
B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.
C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.
D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.
Correct Answer is C
Explanation
A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.
B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.
C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.
D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.
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