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.

Answer and Explanation

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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Correct Answer is []

Explanation

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

A. Muscle layers B. Epidermal layers C. Dermal layers D. Subcutaneous layers E. Bone and ligaments

Correct Answer is ["A","B","C","D"]

Explanation

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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