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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Related Questions
Correct Answer is C
Explanation
A. Determine the need for additional providers: Determining the need for additional providers is typically the responsibility of the hospital administration or incident command team, not the unit nurse.
B. Act as a spokesperson to provide information to the media: Communication with the media is managed by designated public relations personnel or a hospital spokesperson, not the unit nurse.
C. Recommend to the provider a list of clients for early discharge: The unit nurse is responsible for assessing which clients are stable enough for discharge and communicating these recommendations to the provider. This helps prioritize bed availability and ensures appropriate allocation of resources during a disaster.
D. Decide which clients should be transported for a higher level of care: This decision is typically made by the disaster management team or the provider, with input from the nurse. Nurses may report clinical details to help inform the decision but do not make the final determination.
Correct Answer is C
Explanation
A. Flushing the tube with water after feedings helps to prevent tube clogging and ensures adequate delivery of enteral feedings. However, it does not address the diarrhea.
B. While it's important to discard open cans of formula within a specified timeframe to prevent bacterial growth, diarrhea in the client is not directly addressed by discarding formula after 36 hours.
C. The nurse should consider administering feedings at a slower rate to manage diarrhea. This approach can help reduce the incidence of diarrhea as it allows for better absorption of the nutrients.
D. Providing chilled formula is not typically indicated for clients with diarrhea and may not be well-tolerated.
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