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 C

Explanation

A. "My child still wets the bed at least two times per week." Bedwetting (nocturnal enuresis) is common in young children, and while it can be concerning, it is not uncommon for a 4-year-old. Many children still experience bedwetting at this age, and it usually resolves over time.
B. "My child continually asks me the same questions." Continually asking the same questions can be typical for a 4-year-old, as children often seek clarification and reassurance through repetitive questioning. While it may be frustrating, it is generally not a sign of a serious issue.
C. "I have noticed that my child is withdrawn since we switched day care providers." Withdrawal can be a sign of emotional distress, anxiety, or adjustment issues related to the change in daycare. The nurse should further assess the child's emotional and behavioral responses to ensure they are receiving the appropriate support and intervention if needed.
D. "I have a difficult time getting my child to eat green vegetables." Getting the child to eat green vegetables is a common challenge among young children, as they often exhibit food preferences and may be picky eaters. While it is important to encourage healthy eating habits, this issue does not require immediate intervention compared to concerns about emotional withdrawal.

A. The client's left arm is cool to the touch. B. The client's left arm is swollen. C. There is a red streak up the client's left arm. D. The client reports tenderness at the IV insertion site. E. The client reports cramping above the insertion site.

Correct Answer is ["A","B"]

Explanation

A. The client's left arm is cool to the touch. Infiltration occurs when IV fluid leaks into surrounding tissues, leading to decreased circulation in the area. This results in a cool sensation due to the presence of the fluid outside the vein.
B. The client's left arm is swollen. Swelling occurs as IV fluid accumulates in the surrounding tissues instead of remaining in the vein. This is a common sign of infiltration and indicates that the IV site should be assessed and possibly discontinued.
C. There is a red streak up the client's left arm. A red streak is more indicative of phlebitis, which is inflammation of the vein rather than infiltration. Phlebitis often results from irritation due to the IV catheter or the infusing solution.
D. The client reports tenderness at the IV insertion site. Tenderness alone is not a definitive sign of infiltration, as it can also occur with phlebitis or mechanical irritation from the IV catheter. Additional signs such as swelling and coolness are better indicators.
E. The client reports cramping above the insertion site. Cramping is not typically associated with infiltration. It is more commonly seen with certain IV medications that can irritate the vein or cause venous spasm rather than leakage of IV fluids into the tissues.

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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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