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 A
Explanation
A. An advanced practice nurse, such as a nurse practitioner or clinical nurse specialist, has the training to assess medication interactions and adjust prescriptions if necessary. They can evaluate the client's medications, consider potential adverse effects, and collaborate with the prescribing provider. Consulting an advanced practice nurse ensures safe and effective medication management.
B. A psychologist focuses on mental health assessment and therapy but does not prescribe or manage medications. They may help clients cope with medication-related concerns, but they lack the authority to assess or modify prescriptions. Medication-related inquiries should be directed to a medical provider or pharmacist.
C. A social worker assists clients with psychosocial needs, financial concerns, and community resources but does not have the expertise to evaluate medication interactions. They can provide support for medication access or adherence issues but not clinical medication guidance. Medication safety requires consultation with a qualified medical professional.
D. A patient care technician provides basic client care, such as vital sign monitoring and assisting with activities of daily living. They do not have the training to assess medication interactions or provide pharmacological advice. Medication concerns should be referred to a licensed healthcare provider.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Anticipated:
- Administer oxygen at 10 L/min via non-rebreather face mask as needed: The client has late decelerations, indicating possible fetal hypoxia. Providing supplemental oxygen can enhance placental oxygenation and improve fetal status.
- Position the client in lateral side-lying position: This position improves uteroplacental perfusion by relieving compression of the inferior vena cava, which can help resolve late decelerations and improve fetal oxygenation.
- Encourage the client to void every 2 hr: A full bladder can impede fetal descent and contribute to labor discomfort. Regular voiding helps prevent bladder distention and promotes labor progress.
- Administer prophylactic IV antibiotic: The client is positive for Group B streptococcus (GBS), which necessitates prophylactic antibiotic administration during labor to reduce the risk of neonatal infection.
- Evaluate the client for uterine tachysystole: The client's contractions have increased in frequency and intensity. Assessing for excessive uterine activity is critical to prevent fetal distress and complications such as uterine rupture.
Contraindicated:
- Administer magnesium sulfate IV: Magnesium sulfate is used for seizure prophylaxis in preeclampsia or for tocolysis in preterm labor. The client does not have preeclampsia, and labor is at term, making this intervention unnecessary.
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