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.

Answer and Explanation

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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Correct Answer is D

Explanation

A. Ketorolac is an NSAID that carries a risk of gastrointestinal bleeding and is contraindicated in clients with cholelithiasis due to its potential to cause biliary colic.
B. Omeprazole is a proton pump inhibitor used to reduce gastric acid secretion and prevent ulcers but does not provide immediate pain relief.
C. Metoclopramide is a prokinetic agent that helps with gastric emptying and may be used to relieve symptoms such as nausea and vomiting but is not indicated for pain relief.

D. Acetaminophen is a suitable PRN pain medication for a client experiencing moderate abdominal pain due to cholelithiasis. It provides effective analgesia without exacerbating symptoms or causing adverse effects on the gastrointestinal system, which is crucial for clients with gallstone-related pain.

A. Monitor the child's cardiac status. B. Give scheduled doses of acetaminophen every 6 hr. C. Provide stimulation with children of the same age in the play room. D. Administer antibiotics via intermittent IV bolus for 24 hr.

Correct Answer is A

Explanation

A. Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B. While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C. During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D. Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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Correct Answer is A

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