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. Remove the tape by pulling from the center of the dressing. Tape should be removed by pulling toward the wound rather than from the center to avoid skin trauma and unnecessary disruption to the healing tissue. Pulling from the center can increase discomfort and damage surrounding skin.
B. Clean the wound from the center to the outer edges. Cleaning from the center outward prevents the introduction of microorganisms from the surrounding skin into the wound, reducing the risk of further infection. This technique follows the principle of working from the cleanest area to the least clean.
C. Moisten the dressing before removal. A wet-to-dry dressing is meant to adhere to necrotic tissue and debris, which is then removed when the dry dressing is taken off. Moistening it before removal defeats this purpose by softening the dressing, reducing its effectiveness in debriding the wound.
D. Wear sterile gloves to remove the dressing. Clean gloves are appropriate for removing a contaminated dressing. Sterile gloves are necessary for applying the new dressing to maintain an aseptic environment. Using sterile gloves for removal is unnecessary and does not improve infection control.
Correct Answer is D
Explanation
A. Nausea. Epinephrine is not primarily used to treat nausea. It is a sympathomimetic medication that works by stimulating alpha and beta receptors, mainly to counteract severe allergic reactions, including respiratory distress and hypotension. Nausea is not a primary indication for its use.
B. Hand tremors. Epinephrine can cause hand tremors as a side effect due to its stimulant effects on the nervous system. However, it is not used to treat tremors, and the presence of tremors after administration is a common physiological response rather than a therapeutic effect.
C. Hyperglycemia. Epinephrine can increase blood glucose levels by stimulating glycogenolysis and inhibiting insulin secretion. However, it is not used for treating hyperglycemia, and its effects on glucose metabolism are incidental rather than a primary therapeutic action.
D. Shortness of breath. Epinephrine is commonly used to treat anaphylaxis, which can cause airway swelling and bronchospasm leading to shortness of breath. By stimulating beta-2 receptors, epinephrine relaxes bronchial smooth muscles, improving airflow and reducing respiratory distress.
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