A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

Regulate IV fluids to maintain the client's urinary output.

Check the client's WBC count

Use aseptic technique during wound care for the client.

Obtain the client's oxygen saturation levels.

Answer and Explanation

The Correct Answer is D

Partial-thickness burns to the upper torso can compromise respiratory function due to airway inflammation, potential inhalation injury, and impaired chest expansion from pain or edema. Early burn management prioritizes airway, breathing, and circulation (ABCs), with immediate attention to oxygenation status. Respiratory compromise is a leading cause of mortality in burn patients, especially when burns involve the upper body. Therefore, rapid assessment of oxygenation is essential before initiating other interventions.

Rationale:
A. Regulating IV fluids is important in burn management to maintain perfusion and prevent burn shock, but it is not the first priority. Fluid resuscitation is initiated after ensuring airway and breathing are stable. Oxygenation and respiratory status must be assessed first before fluid adjustments are made.

B. Checking the WBC count is useful for evaluating infection or inflammatory response, but it is not an immediate priority in acute burn management. Laboratory values are secondary to stabilizing vital physiological functions such as breathing and circulation. Immediate bedside assessment takes precedence over diagnostic testing.

C. Using aseptic technique during wound care is essential to prevent infection in burn patients. However, wound care is not the first priority in the initial admission phase. Airway and oxygenation status must be addressed before focusing on dressing and wound management interventions.

D. Obtaining oxygen saturation levels is the priority action because it directly assesses the client’s breathing and oxygenation status. Burns to the upper torso may indicate potential inhalation injury or respiratory compromise. Early detection of hypoxia allows for prompt interventions such as oxygen therapy or advanced airway management if needed.

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Correct Answer is C

Explanation

Disaster preparedness in healthcare settings requires prioritizing clients based on acuity, stability, and ongoing treatment needs. During anticipated emergencies such as storms, clients who are stable and receiving routine or maintenance care are considered appropriate for early discharge planning. In contrast, clients with acute respiratory distress, severe immunosuppression, or intensive treatment needs must remain hospitalized. This ensures resources are reserved for those requiring critical care.

Rationale:
A. An infant with respiratory syncytial virus and a respiratory rate of 70/min indicates severe respiratory distress and potential respiratory failure. This client requires close monitoring, oxygen therapy, and possible advanced respiratory support. Discharging this infant would place them at high risk of deterioration and is unsafe during disaster planning.

B. A child with leukemia and an absolute neutrophil count of 200/mm³ is severely immunocompromised and at high risk for life-threatening infections. This level of neutropenia requires protective isolation and inpatient care. Discharge during a storm would expose the child to significant infectious risks and limit access to emergency care.

C. A child with cystic fibrosis receiving a routine annual tune-up is typically in a stable condition undergoing scheduled maintenance therapy such as airway clearance and antibiotic optimization. Cystic fibrosis patients are often stable and can be safely discharged or scheduled for outpatient follow-up during disaster planning. This makes them the most appropriate candidate for early discharge.

D. A child with a new diagnosis of type 1 diabetes mellitus receiving IV insulin is in an acute phase of care requiring close glucose monitoring and insulin titration. This condition carries a risk of hypoglycemia, hyperglycemia, and metabolic instability. Discharging the client during active stabilization would be unsafe and inappropriate in a disaster situation.

A. Clamp the chest tube every 4 hr. B. Empty the collection chamber every 8 hr. C. Place the client in a supine position. D. Ensure the device is kept below the level of the client's chest.

Correct Answer is D

Explanation

Chest tube management is essential in clients with conditions such as pneumothorax, where air or fluid must be removed from the pleural space to restore normal lung expansion. A chest tube system relies on gravity and a water-seal drainage setup to prevent backflow and maintain proper drainage. Incorrect positioning or handling can lead to complications such as tension pneumothorax or loss of negative intrathoracic pressure. Nursing care focuses on maintaining patency, ensuring proper system function, and preventing complications.

Rationale:
A. Clamping the chest tube every 4 hours is contraindicated unless specifically ordered for a brief and controlled purpose, such as changing the drainage system. Routine clamping can cause pressure buildup in the pleural space, potentially leading to a tension pneumothorax, which is life-threatening. Continuous, unobstructed drainage is essential for safe management.

B. Emptying the collection chamber every 8 hours is not standard practice for chest tube drainage systems. The drainage system is typically not emptied by the nurse; instead, the entire collection unit is replaced when full, using sterile technique if required. Frequent manipulation of the system increases infection risk and disrupts the closed drainage system.

C. Placing the client in a supine position is not recommended for optimal chest tube drainage or lung expansion. Clients are typically positioned in semi-Fowler’s or high-Fowler’s position to promote lung expansion and facilitate drainage from the pleural space. Supine positioning may reduce respiratory efficiency and impair drainage effectiveness.

D. Ensuring the device is kept below the level of the client’s chest is essential for proper chest tube function. This positioning allows gravity to facilitate drainage of air and fluid from the pleural space into the collection chamber. If the system is raised above chest level, there is a risk of backflow, which can compromise respiratory function and increase the risk of complications.

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A nurse is assisting in caring for a client who was just admitted with partial-thickness burns to their upper torso. Which of the following actions should the nurse take first?

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