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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Open the dampers of fireplaces. Keeping fireplace dampers open would allow contaminated outdoor air to enter the home, increasing exposure to harmful chemicals. During an outdoor chemical disaster, it is essential to seal the home as much as possible to prevent infiltration of toxic substances.
B. Cover heat registers with plastic and tape. Sealing heat registers helps prevent outside air from circulating into the home through ventilation systems. This precaution reduces exposure to airborne chemicals by limiting pathways for contamination. Creating an airtight environment is a key strategy in shelter-in-place recommendations during chemical disasters.
C. Exit the home as quickly as possible. Evacuating during an outdoor chemical disaster may increase the risk of exposure if toxic fumes are present. Authorities typically advise sheltering in place with sealed windows and doors unless an evacuation order is issued. Leaving should only occur when officials confirm that it is safe.
D. Turn on ceiling fans and air conditioners. Running ventilation systems like fans and air conditioners can draw in outside air, increasing exposure to hazardous chemicals. Instead, all air systems should be turned off to minimize circulation of contaminated air within the home.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}
Explanation
Rationale for Correct Options:
- Late decelerations on fetal heart rate (FHR) – First Priority
Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus is not receiving adequate oxygen. This is the most urgent concern because prolonged fetal distress can lead to hypoxia and acidosis, increasing the risk of complications such as stillbirth or emergency cesarean birth. Nursing Actions: Reposition the client to left lateral position to improve placental perfusion. Administer oxygen at 10 L/min via a non-rebreather mask. Increase IV fluids to improve maternal circulation. Stop oxytocin if it's being used, as it may be causing excessive contractions. Notify the provider immediately for further interventions, such as potential intrauterine resuscitation or emergent delivery.
- Positive Group B streptococcus (GBS) status – Second Priority
The client tested positive for GBS, a bacterial infection that can be transmitted to the newborn during birth, leading to neonatal sepsis, pneumonia, or meningitis. While this is a significant concern, it is secondary to the immediate fetal distress from late decelerations. Nursing Actions: Administer IV antibiotics (penicillin G or an alternative) as ordered to prevent neonatal infection. Monitor for signs of infection in the newborn after delivery.
Rationale for Incorrect Options:
- Severe back pain rated 10/10 – Pain management is important, but fetal distress takes precedence over maternal discomfort.
- Restlessness and irritability – These could indicate maternal distress or labor progression, but they are not as urgent as fetal oxygenation.
- Increasing contraction intensity and frequency – This is expected as labor progresses but is not immediately life-threatening.
- Fatigue and emotional distress – While support is essential, it is not a priority over fetal well-being or preventing neonatal infection.
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