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 C
Explanation
A. Asking the client to point their toes before applying the stockings is an appropriate action. This maneuver helps to flex the foot, making it easier to apply the stockings and ensuring they fit properly without causing discomfort.
B. Turning the stockings inside out before applying them is an acceptable practice as it can make them easier to put on and ensure they fit well on the client’s leg. This action does not require intervention.
C. Ensuring that creases in the stockings are on the front of the client's legs requires intervention. The stockings should be applied smoothly and without creases to prevent pressure areas, which could lead to skin breakdown or complications. Creases should be avoided on any part of the stockings that may cause discomfort or impede circulation.
D. Applying the stockings before the client gets out of bed is appropriate. Antiembolic stockings are often applied while the client is in bed to prevent complications associated with immobility, such as deep vein thrombosis (DVT). This action supports patient safety and comfort.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Rationale for Correct Choices:
Chorioamnionitis is a bacterial infection of the amniotic fluid and fetal membranes, which can develop when the protective barrier is compromised due to prolonged rupture of membranes. This client reported clear fluid discharge the previous evening, indicating that the membranes have been ruptured for an extended period. The risk of infection increases significantly as time progresses. Additionally, the client exhibits signs of maternal restlessness and increased fetal heart rate, which could indicate an early response to infection or fetal distress.
Hemorrhage is a significant risk during labor, especially as the cervix approaches full dilation and the client exhibits increasing amounts of blood-tinged vaginal discharge. The client’s history of previous pregnancy loss and current cervical changes suggest that monitoring for postpartum hemorrhage will be essential, particularly after delivery.
Rationale for Incorrect Choices:
Disseminated intravascular coagulopathy is a severe complication associated with conditions such as placental abruption, preeclampsia, or amniotic fluid embolism. However, this client does not exhibit hallmark signs such as widespread bruising, uncontrolled bleeding, or abnormal clotting, making this a less likely immediate risk.
Seizures are characteristic of eclampsia, which is typically preceded by severe preeclampsia. While the client is restless and experiencing significant pain, there are no findings of hypertension, hyperreflexia, or neurological disturbances such as visual changes or altered mental status, making seizures an unlikely concern at this time.
Preeclampsia is a hypertensive disorder of pregnancy characterized by elevated blood pressure, proteinuria, and systemic symptoms. This client has stable blood pressure readings within the normal range, no evidence of proteinuria, and no indications of significant organ dysfunction, making preeclampsia an unlikely concern.
Dehydration is a potential concern due to the client’s nausea, vomiting, and lack of recent oral intake. However, there are no immediate signs of hemodynamic instability, such as hypotension or tachycardia, suggesting that dehydration is not the most pressing concern at this moment.
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