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?

Use aseptic technique during wound care for the client.

Obtain the client's oxygen saturation levels.

Check the client's WBC count.

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

Answer and Explanation

The Correct Answer is B

A. Use aseptic technique during wound care for the client. While using aseptic technique is essential for preventing infection during wound care, it is not the immediate priority upon admission. The nurse must first assess the client's airway and oxygenation status.
B. Obtain the client's oxygen saturation levels. Obtaining the client's oxygen saturation levels is the priority action. Clients with burns, especially those affecting the upper torso, may have compromised airway patency or inhalation injury. Assessing oxygen saturation is crucial for determining the need for supplemental oxygen or further airway interventions.
C. Check the client's WBC count. Checking the client's white blood cell (WBC) count is important for evaluating potential infection and overall health status, but it is not an immediate priority in the acute phase of burn management. The nurse should focus first on airway and respiratory assessment.
D. Regulate IV fluids to maintain the client's urinary output. Regulating IV fluids to maintain urinary output is an important action in managing burn clients, as fluid resuscitation is critical. However, it should be done after ensuring the client's airway and oxygenation are stable, as inadequate oxygenation could complicate fluid resuscitation efforts.

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Correct Answer is D

Explanation

A. "You should avoid exercising for the next 6 weeks." Exercise is encouraged after a total hip arthroplasty to promote circulation, prevent complications such as deep vein thrombosis, and strengthen the muscles supporting the hip joint. However, high-impact activities should be avoided until cleared by the healthcare provider.
B. "You should avoid putting a pillow between your legs when in bed." Placing a pillow between the legs, especially while sleeping, helps maintain proper hip alignment and prevents excessive internal rotation or adduction, reducing the risk of dislocation.
C. "You should avoid lying on your right side." Lying on the operative side is not necessarily contraindicated, but it should be done with caution and with proper support. Clients are usually advised to lie on their non-operative side with a pillow between their legs for alignment.
D. "You should avoid crossing your legs for 3 months." Crossing the legs can cause hip adduction and internal rotation, increasing the risk of dislocation of the prosthetic joint. Clients are typically instructed to avoid crossing their legs for at least 3 months or until cleared by their provider.

A. "Your baby will require Apgar scoring every 10 minutes after birth." B. "Your baby's decelerations on the monitor could be caused by your positioning." C. "You should receive betamethasone prior to delivery." D. "You will begin pushing when you have dilated more." E. “I will be monitoring your temperature closely." F. "During this stage of your labor, you're not allowed to receive pain medication." G. "You can have some ice chips, if you would like."

Correct Answer is ["B","D","E","G"]

Explanation

A. "Your baby will require Apgar scoring every 10 minutes after birth." Apgar scores are assessed at 1 and 5 minutes after birth. Additional assessments are only performed if there are concerns about the newborn’s condition, not at 10-minute intervals.
B. "Your baby's decelerations on the monitor could be caused by your positioning." Late decelerations were noted at 1530, which may indicate uteroplacental insufficiency. Maternal positioning can contribute to decelerations by compressing the umbilical cord or reducing placental perfusion. Repositioning, oxygen administration, and IV fluid boluses may help improve fetal oxygenation.
C. "You should receive betamethasone prior to delivery." Betamethasone is used to enhance fetal lung maturity in preterm labor before 34 weeks of gestation. Since this client is at 37 weeks, betamethasone is not needed.
D. "You will begin pushing when you have dilated more." The client is currently at 9 cm dilation, which is the transition phase of labor. Pushing should not begin until full cervical dilation at 10 cm to prevent cervical trauma and ensure effective labor progression.
E. “I will be monitoring your temperature closely." The client has ruptured membranes, which increases the risk of infection (chorioamnionitis). Frequent temperature monitoring is essential to detect early signs of infection.
F. "During this stage of your labor, you're not allowed to receive pain medication." Pain management options are available at all stages of labor. IV opioids may be avoided close to delivery to prevent neonatal respiratory depression, but epidural anesthesia can still be maintained.
G. "You can have some ice chips, if you would like." Clear fluids and ice chips are generally allowed during labor to help maintain hydration unless there is a contraindication, such as the need for an emergent cesarean under general anesthesia.

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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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Explanation

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