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. Bradycardia B. Nausea and vomiting C. Increased urinary output D. Hyperactive bowel sounds

Correct Answer is B

Explanation

A. Bradycardia: Peritonitis is usually associated with tachycardia, not bradycardia.

B. Nausea and vomiting: These are common early signs of peritonitis, often accompanied by abdominal pain and fever.

C. Increased urinary output: Clients with peritoneal dialysis often have reduced kidney function, so urine output is generally decreased, not increased.

D. Hyperactive bowel sounds: Bowel sounds are usually diminished or hypoactive in peritonitis due to inflammation.

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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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