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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A: Methylphenidate should be taken preferably 30 to 45 minutes before meals to reduce the risk of stomach upset. Furthermore, food interferes with its absorption.
B: Administering methylphenidate at bedtime is incorrect because it is a stimulant and can interfere with sleep.
C: Avoiding foods containing tyramine is not relevant for methylphenidate; it is more commonly a concern with certain antidepressants such as MAO inhibitors.
D: There is no need to avoid excess sodium intake specifically related to methylphenidate usage; this advice does not pertain to the side effects or interactions of the medication.
Correct Answer is B
Explanation
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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