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 A
Explanation
A. Flushing the NG tube with 0.9% sodium chloride helps maintain patency and prevents obstruction. It is a standard practice to flush NG tubes before and after administering medications or feedings.
B. NG tubes are not routinely replaced every 24 hours unless there is a specific clinical indication to do so.
C. The position of the client depends on the clinical situation, but supine position alone does not address NG tube care.
D. Suction pressure should be set according to the physician's orders and the patient's tolerance, but it should not be increased arbitrarily without clinical indication.
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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