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 B

Explanation

A. Evaluating the patient's level of pain after medication administration: This is important but comes after the medication is given.

B. Ensuring a bag valve mask (BVM) is at the bedside: Opioids and sedatives depress respiratory drive. Emergency resuscitation equipment (like a BVM) must be ready in case of respiratory compromise.

C. Verification of allergies to medications: Important, but verifying allergies should already be done before administering any meds; not the priority here.

D. Documenting the level of pain before medication administration: Also important, but secondary to safety preparation.

A. Raisins B. Bananas C. Green beans D. Asparagus E. Tomatoes

Correct Answer is ["A","B","E"]

Explanation

A. Raisins: Dried fruits like raisins are concentrated sources of potassium and should be avoided in CKD.

B. Bananas: Bananas are high in potassium and commonly restricted in CKD to prevent hyperkalemia.

C. Green beans: Green beans are relatively low in potassium and generally safe for a renal diet.

D. Asparagus: Asparagus has moderate potassium levels but can be included in moderation depending on the client's labs.

E. Tomatoes: Tomatoes, especially in processed forms like sauce or juice, are high in potassium.

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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

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