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
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Related Questions
Correct Answer is C
Explanation
A. While hospice care may be appropriate for the client, it does not directly address the client's reported depression.
B. Discussing advance directives is important for end-of-life care planning, but it may not address the client's current emotional needs.
C. Offering spiritual support acknowledges the client's emotional distress and provides an opportunity for comfort and guidance that aligns with the client's values and beliefs.
D. Offering medication without further assessment or exploration of the client's feelings may not be the most therapeutic response to the reported depression.
Correct Answer is C
Explanation
A. Using a child as an interpreter can be inappropriate and may not ensure accurate communication, especially for sensitive topics such as medical history and symptoms.
B. While involving the client's partner may seem helpful, it may not ensure accurate translation, and the partner may not be proficient in medical terminology.
C. Requesting a female interpreter through the facility ensures accurate and confidential communication while respecting the client's cultural preferences and privacy.
D. While asking a nursing student who speaks the same language as the client may seem convenient, it may not ensure accurate translation, and the student may not have the necessary training in medical interpretation.
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