While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Assess papillary reactions to light.

Measure and record abdominal girth.

Auscultate over main stem bronchus.

Determine time of last oral intake.

Answer and Explanation

The Correct Answer is C

A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.

B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.

C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.

D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Pressure injuries: These can indicate neglect or inadequate care, as they often develop from prolonged periods of immobility or poor hygiene.

Poor hygiene: A foul odor and unclean environment, along with a lack of clothing, can be signs of neglect or mistreatment.

Malnutrition: The client's low weight (98 lb or 44.5 kg) and a lack of appropriate nutrition could indicate inadequate care and potential mistreatment, contributing to overall poor health and well-being.

A. Reassure the client that the client's child will be allowed to visit. B. Obtain a detailed report from the nurse transferring the client. C. Provide the client written information about end-of-life care. D. Mark the chart with client's request for no heroic measures.

Correct Answer is B

Explanation

A. While reassuring the client about visiting arrangements is supportive, it is not as critical for ensuring continuity of care.

B. Obtaining a detailed report from the transferring nurse is crucial to ensure all relevant information and the client’s wishes are communicated effectively.

C. Providing written information about end-of-life care is helpful but secondary to ensuring accurate communication of the client’s care preferences.

D. Marking the chart is important, but the immediate priority is ensuring the complete and accurate transfer of care information.

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While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse reviews the findings in the history and physical. Drag from Word Choices to complete the sentence. The nurse recognizes that dropdown, dropdown, and dropdownare findings consistent with elder mistreatment.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A","dropdown-group-3":"C"}

Explanation

Correct Answer is B

Explanation

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