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 D

Explanation

A. Docusate. Docusate is a stool softener that helps prevent constipation, which can be beneficial for clients taking enoxaparin, as straining during bowel movements can increase the risk of bleeding. It does not have anticoagulant properties and does not pose a significant risk of increased bleeding.
B. Cimetidine. Cimetidine, an H2-receptor antagonist used to reduce stomach acid, does not directly increase bleeding risk. However, long-term use can affect liver metabolism and interact with some anticoagulants, but it is not considered unsafe for routine use with enoxaparin.
C. Calcium supplement. Calcium supplements are commonly used for bone health and do not interfere with enoxaparin’s anticoagulant effects. They do not increase bleeding risk and are generally safe for clients taking anticoagulants.
D. Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that inhibits platelet aggregation and increases the risk of gastrointestinal bleeding. When combined with enoxaparin, which is a low-molecular-weight heparin, the risk of bleeding complications, including gastrointestinal and intracranial hemorrhage, significantly increases. Clients should be advised to use acetaminophen for pain relief instead of NSAIDs while taking enoxaparin.

A. Initiate droplet precautions. B. Administer fluconazole to the preschooler. C. Monitor the preschooler's urine for protein. D. Request an x-ray of the preschooler's neck.

Correct Answer is A

Explanation

A. Initiate droplet precautions. Respiratory syncytial virus (RSV) is primarily transmitted through respiratory secretions, requiring contact and droplet precautions to prevent the spread. Isolation measures, including wearing masks and gowns, help protect healthcare workers and other patients.
B. Administer fluconazole to the preschooler. Fluconazole is an antifungal medication, which is not effective against RSV, a viral infection. Treatment for RSV is mainly supportive, focusing on airway management, hydration, and oxygen therapy as needed.
C. Monitor the preschooler's urine for protein. Proteinuria is associated with kidney conditions such as nephrotic syndrome, not RSV. RSV primarily affects the respiratory system, causing bronchiolitis and increased mucus production rather than kidney involvement.
D. Request an x-ray of the preschooler's neck. A neck x-ray is typically used to evaluate airway obstruction from conditions like epiglottitis. RSV affects the lower respiratory tract, leading to bronchiolitis, and does not usually require imaging unless complications arise.

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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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