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 D

Explanation

A. Elevating the legs is beneficial for venous circulation, but not for arterial circulation, which can worsen with elevation.

B. TED hose are primarily used to promote venous return and prevent deep vein thrombosis, not to enhance arterial circulation.

C. Inspecting feet daily is essential for managing diabetes-related foot complications, but it does not directly improve arterial circulation.

D. Smoking cessation is critical for improving arterial circulation as smoking is a major risk factor for peripheral artery disease. Stopping smoking can significantly enhance blood flow and reduce pain.

A. Administer PRN oral analgesics to a client with a history of chronic pain. B. Transport a client who is receiving IV fluids to the radiology department. C. Supervise a newly hired graduate nurse during an admission assessment. D. Complete ongoing focused assessments of a client with wrist restraints.

Correct Answer is C

Explanation

A. Administering PRN oral analgesics can be managed by both RNs and PNs, as this task does not require advanced assessment or decision-making.

B. Transporting a client who is receiving IV fluids can be safely done by UAPs with appropriate supervision.

C. Supervision and evaluation of the performance of a newly hired graduate nurse during an admission assessment are appropriate tasks for an RN, given their experience and clinical judgment.

D. Ongoing focused assessments of a client with wrist restraints require a higher level of clinical judgment and decision-making, which is best handled by an RN.

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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

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