A nurse in the emergency department is assessing a newly admitted client who is experiencing drooling and hoarseness following a burn injury. Which of the following actions should the nurse take first?
Obtain a blood specimen for ABG analysis.
Apply 100% humidified oxygen.
Obtain a baseline ECG.
Insert an 18-gauge IV catheter.
The Correct Answer is B
A. Obtain a blood specimen for ABG analysis. Important, but not the first action.
B. In a client with burn injuries experiencing signs of airway compromise (drooling, hoarseness), the first action should be to ensure adequate oxygenation. Applying 100% humidified oxygen can help manage potential airway edema.
C. Obtain a baseline ECG. Necessary for monitoring but secondary to securing the airway.
D. Insert an 18-gauge IV catheter. Essential for fluid resuscitation and medication administration, but after ensuring adequate oxygenation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing a cooling blanket may help reduce fever associated with a thyroid storm but is not the priority over monitoring the cardiac rhythm.
B. In a thyroid storm, the client is at risk for severe cardiovascular complications, including tachycardia, arrhythmias, and heart failure. Therefore, the nurse's priority action is to monitor the client's cardiac rhythm continuously to detect any abnormalities promptly and intervene as needed.
C. Administering 0.9% sodium chloride IV may be necessary to maintain fluid balance, but it's not the priority over cardiac monitoring.
D. Obtaining the client's blood glucose may be relevant but is not the priority in the acute management of a thyroid storm.
Correct Answer is A
Explanation
A. Raised facial rash, often in a "butterfly" distribution across the cheeks and bridge of the nose, is a characteristic manifestation of systemic lupus erythematosus.
B. Hemangiomas are not typically associated with systemic lupus erythematosus.
C. Kaposi's sarcoma lesions are associated with immunosuppression, such as in HIV infection, and are not a typical finding in systemic lupus erythematosus.
D. Psoriasis is a separate autoimmune condition characterized by red, scaly patches on the skin and is not typically associated with systemic lupus erythematosus.
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