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 B

Explanation

A. Identifying information as a late entry is not appropriate until the system issue is resolved.

B. Notifying the information services department is essential to address the system failure and seek assistance in resolving the issue.

C. Waiting for notification may delay addressing the problem and does not help in the immediate resolution.

D. Printing the EMR from the backup server might be necessary later but does not address the immediate need to fix the system issue.

A. Ear pain and fever. B. Positive Epstein-Barr, and malaise. C. Increased BUN and serum creatinine. D. Elevated WBC and sedimentation rate.

Correct Answer is B

Explanation

A. Ear pain and fever are not characteristic symptoms of mononucleosis.

B. Mononucleosis is often associated with a positive Epstein-Barr virus (EBV) test and symptoms of malaise, fatigue, and lymphadenopathy.

C. Increased BUN and serum creatinine indicate kidney function issues, which are not typically associated with mononucleosis.

D. While elevated WBC and sedimentation rate can occur, they are nonspecific and can be seen in many conditions; they are not defining symptoms of mononucleosis.

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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

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