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. Use the arms to pick up heavy items. Lifting heavy objects using only the arms increases strain on the back, worsening pain. Pregnant clients should bend at the knees and lift with their legs while keeping the back straight to reduce stress on the lumbar region.
B. Raise chairs to keep knees lower than hips. Sitting with knees lower than the hips can worsen lumbar lordosis, increasing back discomfort. Instead, knees should be at or slightly above hip level to maintain spinal alignment and reduce strain on the lower back.
C. Perform pelvic rocking exercises several times per day. Pelvic rocking strengthens and stretches lower back muscles, improving flexibility and reducing discomfort. This exercise helps alleviate strain from the growing uterus and supports better posture, decreasing back pain.
D. Sit in a hot tub for 30 min every evening. Prolonged exposure to high temperatures, such as in a hot tub, can cause maternal hyperthermia, increasing the risk of fetal neural tube defects. Warm baths are a safer option to relieve muscle tension without harmful effects.

Correct Answer is []

Explanation

Potential Condition:

Kawasaki disease: The child presents with prolonged fever, mucocutaneous changes (cracked lips, red tongue), extremity changes (edema, peeling skin), cervical lymphadenopathy, and elevated inflammatory markers (WBC, ESR, CRP, and platelets), all of which are consistent with Kawasaki disease.

Actions to Take

Administer IVIG: IVIG is the primary treatment to reduce inflammation and prevent coronary artery aneurysms.

Administer high-dose aspirin: Used in the acute phase to reduce inflammation and fever and in the subacute phase to prevent clot formation.

Parameters to Monitor

Heart rhythm: Kawasaki disease can cause myocarditis and coronary artery aneurysms, leading to arrhythmias.

Chest discomfort: A sign of coronary artery complications, including aneurysms or ischemia.

Rationale for Incorrect Diagnoses:

Bacterial endocarditis: Does not cause peeling skin or bright red tongue. Fever would be accompanied by murmurs and a history of heart defects.

Nephrotic syndrome: Characterized by severe proteinuria, edema, and hypoalbuminemia, which are absent here.

Acute post-streptococcal glomerulonephritis: Would present with recent strep infection, hematuria, hypertension, and periorbital edema, which are not mentioned.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is []

Explanation

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