Free ATI Medical Surgical practice for ATI Detailed Answer Key Medical Surgical (ATI RN). Answer 50 nursing exam-style questions with rationales, exam mode, and
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
In a client with a sucking chest wound, the priority is to administer oxygen via nasal cannula to improve oxygenation. The client's blood pressure, weak pulse rate, and elevated respiratory rate indicate hypovolemic shock, so increasing oxygen supply is crucial. Raising the foot of the bed, removing the dressing, or preparing to insert a central line are not immediate actions needed for a client with a sucking chest wound and signs of shock.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
Select the best answer.
Explanation:
The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.
The client with a chest tube after a coronary artery bypass graft has significantly slowed drainage. What action is most important for the nurse to take?
Select the best answer.
Explanation:
If the drainage from the chest tube decreases significantly, it may indicate a blockage by a clot, potentially leading to cardiac tamponade. The nurse's priority action should be to notify the healthcare provider immediately for further evaluation and intervention. Increasing suction, re-positioning the chest tube, or disassembling the tubing independently are not appropriate actions without healthcare provider guidance in this situation.
In an emergency department, a healthcare provider is preparing to care for a client with multiple system trauma following a motor vehicle crash. What should be the priority focus of care?
Select the best answer.
Explanation:
In a client with multiple system trauma, airway protection is the priority focus of care. Ensuring a patent airway is crucial for oxygenation and ventilation, which are essential for maintaining vital functions. Without a clear airway, the client's oxygenation and ventilation could be compromised, leading to severe consequences. While decreasing intracranial pressure, stabilizing cardiac arrhythmias, and preventing musculoskeletal disability are important aspects of care, ensuring airway protection takes precedence in this emergency situation.
A client has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should be taken?
Select the best answer.
Explanation:
When a client with a chest tube connected to wall suction complains of chest burning, it may indicate that the tube is irritating or compressing nearby tissues. Repositioning the client can help relieve this irritation by ensuring the tube is not kinked or pulling on the tissues. Increasing suction, stripping the tube, or clamping it are not appropriate actions and could potentially worsen the situation or cause harm.
A client with a history of gastrointestinal bleeding is taking warfarin (Coumadin). Which instruction should the nurse include in the teaching plan?
Select the best answer.
Explanation:
The correct instruction for a client taking warfarin, an anticoagulant, is to report any signs of bruising or bleeding to the healthcare provider promptly. This is crucial as these symptoms may indicate over-anticoagulation, which can lead to serious complications. Monitoring for signs of bleeding is essential to adjust the medication dosage or take appropriate measures to ensure the client's safety.
The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?
Select the best answer.
Explanation:
In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.
A client had a bronchoscopy 2 hours ago and asks for a drink of water. Which action should the nurse take next?
Select the best answer.
Explanation:
After a bronchoscopy, a topical anesthetic affects the gag reflex. Therefore, the nurse should assess the client's gag reflex before providing any food or water to ensure its return. This assessment is crucial to prevent aspiration or choking risk in the client.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
Select the best answer.
Explanation:
The most appropriate action for the nurse in this scenario is to teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including pulmonary embolism (PE). In a case where a client has no known risk factors for PE, testing for this genetic disorder is crucial to determine if it is a contributing factor. Encouraging the client to walk or referring them to smoking cessation classes, while beneficial for overall health, are not directly relevant to the development of a PE in this specific case. While it is true that sometimes no cause for a disease is found, prematurely assuming this without appropriate investigations may lead to missed opportunities for preventive measures or treatments.
A student asks the faculty to explain best practices when communicating with a person from the LGBTQ community. What answer by the faculty is most accurate?
Select the best answer.
Explanation:
It is essential not to make assumptions about the health needs of individuals from the LGBTQ community. Each person is unique, and assuming their needs based on their sexual orientation or gender identity can lead to incorrect care and communication. By being open-minded and avoiding assumptions, healthcare providers can create a safe and supportive environment for LGBTQ individuals to discuss their health needs openly and honestly.
When teaching a client with chronic obstructive pulmonary disease who will start using fluticasone via MDI twice daily, which instruction should the nurse include?
Select the best answer.
Explanation:
It is crucial for clients using inhaled corticosteroids like fluticasone to inspect their mouths daily for signs of oral thrush, a common side effect. Checking the mouth can help identify lesions early, allowing for timely intervention to prevent worsening of the condition. Monitoring heart rate is not specifically required for this medication. Fluticasone is a maintenance medication used to manage COPD, not to relieve acute attacks. Skipping doses, especially in the morning, can lead to inadequate control of COPD symptoms.
A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?
Select the best answer.
Explanation:
In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.
What should the nurse prioritize when monitoring an older adult client immediately following a bronchoscopy?
Select the best answer.
Explanation:
Following a bronchoscopy, the priority for the nurse is to confirm the gag reflex in the older adult client. This is crucial to ensure that the client's airway is protected and free from any obstruction or aspiration. Monitoring the gag reflex helps in preventing complications such as aspiration pneumonia. While auscultating breath sounds, observing for confusion, and measuring blood pressure are important assessments, confirming the gag reflex takes precedence in this situation to maintain airway patency and prevent potential respiratory complications.
A client with emphysema is being cared for by a nurse. Which of the following findings should the nurse not expect to assess in this client?
Select the best answer.
Explanation:
Emphysema is a chronic lung condition characterized by shortness of breath (dyspnea), a barrel-shaped chest due to hyperinflation of the lungs (barrel chest), and clubbing of the fingers (enlargement of fingertips). Bradycardia (slow heart rate) is not typically associated with emphysema. In emphysema, the primary focus is on respiratory complications rather than cardiac issues.
A client has a new diagnosis of myasthenia gravis. For which of the following manifestations should the nurse monitor?
Select the best answer.
Explanation:
In myasthenia gravis, a neuromuscular disorder characterized by muscle weakness and fatigue, weakness is a common manifestation due to the immune system attacking the communication between nerves and muscles. Monitoring for weakness is crucial to assess the disease progression and determine the effectiveness of treatment. Confusion is not a typical manifestation of myasthenia gravis. Increased intracranial pressure and increased urinary output are not directly associated with this condition.
After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?
Select the best answer.
Explanation:
Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.
A healthcare professional is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the healthcare professional expect?
Select the best answer.
Explanation:
Respiratory acidosis is a condition characterized by increased carbon dioxide levels in the blood, resulting in acidosis. One of the potential consequences of respiratory acidosis is the development of electrolyte imbalances, particularly hyperkalemia. Hyperkalemia can lead to cardiac conduction abnormalities, manifested as widened QRS complexes on an electrocardiogram (ECG). Therefore, in a client with respiratory acidosis, the healthcare professional should expect to find widened QRS complexes as a result of the associated hyperkalemia.
A client in the late stage of inhalation anthrax requires a plan of care. What is appropriate to include in the plan of care?
Select the best answer.
Explanation:
In the late stage of inhalation anthrax, respiratory support is crucial due to the potential for respiratory failure. Providing oxygen therapy and maintaining airway patency are essential components of care to improve oxygenation and support respiratory function. Placing the client in droplet isolation is not necessary as inhalation anthrax is not transmitted from person to person through respiratory droplets. Administering antihypertensive medications is not indicated in the treatment of inhalation anthrax. Monitoring for ascites is not a priority in the late stage of inhalation anthrax.
Which action should the nurse take to reduce the risk of ventilator-associated pneumonia in a client with an endotracheal tube receiving mechanical ventilation?
Select the best answer.
Explanation:
Ventilator-associated pneumonia (VAP) is a common complication in clients receiving mechanical ventilation. Oral hygiene is crucial in reducing the risk of VAP. Brushing the client's teeth with a suction toothbrush every 12 hours helps prevent bacterial colonization in the oral cavity, which can be aspirated into the lungs. Positioning the head of the bed flat can increase the risk of aspiration. Turning the client every 4 hours is important for preventing pressure ulcers but not directly related to reducing VAP. Providing humidity in the ventilator tubing helps maintain airway moisture but does not directly address the risk of VAP.
A home health nurse visits a client who has COPD and receives oxygen at 2 L/min via nasal cannula. The client reports difficulty breathing. Which of the following actions is the nurse's priority?
Select the best answer.
Explanation:
When a client with COPD on oxygen therapy reports difficulty breathing, the priority action for the nurse is to assess the client's respiratory status. This involves evaluating the client's oxygen saturation levels, respiratory rate, effort of breathing, lung sounds, and overall respiratory distress. By assessing the client's respiratory status, the nurse can determine the severity of the situation and make appropriate decisions regarding further interventions, such as adjusting oxygen flow rate, providing respiratory treatments, or seeking emergency assistance if necessary.
A healthcare professional assesses a client who is experiencing an acute asthma attack. Which assessment finding requires immediate intervention?
Select the best answer.
Explanation:
A silent chest in a client experiencing an acute asthma attack indicates severe airway obstruction and impending respiratory failure. It is a critical finding that requires immediate intervention as it signifies a lack of airflow and ventilation. Loud wheezing, increased respiratory rate, and use of accessory muscles are common signs of an asthma attack and indicate the body's attempt to compensate. However, a silent chest suggests a dangerous lack of airflow that necessitates urgent medical attention to prevent respiratory arrest.
How does the pain of a myocardial infarction (MI) differ from stable angina?
Select the best answer.
Explanation:
The pain of a myocardial infarction (MI) is often accompanied by shortness of breath and feelings of fear or anxiety. Unlike stable angina, the pain of an MI typically lasts longer than 15 minutes and is not relieved by nitroglycerin. Additionally, it can occur without a known cause, unlike stable angina which often has a trigger such as exertion.
After a thoracentesis, a healthcare provider assesses a client. Which assessment finding warrants immediate action?
Select the best answer.
Explanation:
A deviated trachea indicates a tension pneumothorax, a life-threatening emergency. This condition can rapidly lead to respiratory failure and requires immediate intervention. The other assessment findings, such as pain level, mild drainage, and slightly decreased oxygen saturation, are within an expected range after a thoracentesis and do not indicate an immediate threat to the client's life.
A nurse teaches a client with tuberculosis (TB) who is being discharged. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
Clients with tuberculosis should not return to work until they are no longer contagious and have been cleared by their healthcare provider. This usually requires several weeks of treatment. The other statements are correct and indicate understanding.
A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (SATA)
Select the best answer.
Explanation:
Hypertension, obesity, smoking, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor as it is a natural process of life.
A patient is receiving discharge instructions after experiencing a stroke. Which instruction is most important for preventing another stroke?
Select the best answer.
Explanation:
The correct answer is to take prescribed antihypertensive medications regularly. Hypertension is a major risk factor for stroke, and controlling blood pressure through medication is crucial in preventing recurrent strokes. While physical therapy, diet, and follow-up appointments are also important aspects of post-stroke care, managing hypertension with medication takes precedence due to its direct impact on stroke prevention.
A client tests positive for alpha1-antitrypsin (AAT) deficiency and asks the nurse, What does this mean? How should the nurse respond?
Select the best answer.
Explanation:
Alpha1-antitrypsin (AAT) deficiency is associated with a higher risk of chronic obstructive pulmonary disease (COPD), especially if the individual smokes. This condition is caused by a recessive gene. Individuals with one allele typically produce enough AAT to prevent COPD unless they smoke. However, those with two alleles are at high risk for COPD even without exposure to smoke or other irritants. Being a carrier of AAT deficiency does not guarantee that one's children will develop the disease; it depends on the AAT levels of the partner. While involving a genetic counselor may be beneficial in the long run, the immediate concern of the client's question should be addressed first.
A nurse is evaluating a 3-day diet history with a client who has an elevated lipid panel. What meal selection indicates the client is managing this condition well with diet?
Select the best answer.
Explanation:
The diet recommended for this client would be low in saturated fats & red meat, high in vegetables & whole grains (fiber), low in salt, & low in trans-fat. The best choice is the chicken with broccoli & tomatoes. The French fries have too much fat & the iceberg lettuce has little fiber. The catfish is fried. The spaghetti dinner has too much red meat & no vegetables.
A client with a chest tube connected to a closed drainage system needs to be transported to the x-ray department. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
When transporting a client with a chest tube connected to a closed drainage system, it is crucial to keep the drainage system below the level of the client's chest at all times. This positioning prevents the backflow of drainage into the client's chest, reducing the risk of complications. Clamping the chest tube, disconnecting it from the drainage system, or emptying the collection chamber are incorrect actions and can potentially harm the client or lead to complications.
A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
Select the best answer.
Explanation:
In this situation, the priority action is to provide high-flow oxygen to the client. Sudden onset dyspnea and severe chest pain can be indicative of a pulmonary embolism, which is a life-threatening emergency. Oxygen therapy helps improve oxygenation and stabilizes the client's condition. Checking for Chvostek's sign, administering IV vasopressors, or monitoring for a headache are not the immediate priorities in this critical situation.
The healthcare provider is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the healthcare provider that the chest tube is functioning properly?
Select the best answer.
Explanation:
Fluctuation of the fluid level within the water seal chamber indicates proper functioning of the chest tube. This fluctuation reflects the normal ebb and flow of air and fluid in the pleural space, demonstrating that the system is maintaining the appropriate pressure. Continuous bubbling in the water seal chamber may indicate an air leak, absence of fluid in the drainage tubing suggests a blockage, and equal amounts of fluid drainage in each collection chamber are not expected in this system.
After an open lung biopsy, a nurse assesses a client. Which assessment finding is matched with the correct intervention?
Select the best answer.
Explanation:
After an open lung biopsy, a potential complication is pneumothorax, often indicated by reduced or absent breath sounds. The nurse should promptly notify the physician to address this serious issue and ensure timely intervention.
A client is scheduled for a colonoscopy and receiving education from a healthcare provider. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
The correct answer is D because clients are typically instructed to avoid solid foods for 12-24 hours before a colonoscopy, not a full 24 hours. This statement indicates a need for further teaching to ensure the client follows the correct dietary instructions for the procedure.
A client with chronic obstructive pulmonary disease is being taught by a nurse. Which nutritional information should the nurse include in the teaching? (SATA)
Select the best answer.
Explanation:
In chronic obstructive pulmonary disease, it's important to consider the impact of nutrition on respiratory function. Eating high-fiber foods can lead to increased gas production, causing abdominal bloating and potentially worsening shortness of breath. Therefore, it is advisable for clients with COPD to avoid high-fiber foods to prevent these issues. Resting before meals can help manage dyspnea, and having smaller, more frequent meals can prevent bloating. Increasing calorie and protein intake is essential to prevent malnourishment in COPD patients. Additionally, limiting carbohydrate intake is crucial as it can increase carbon dioxide production, leading to a higher risk of acidosis in these individuals.
A healthcare worker is caring for a group of clients in an infectious disease unit. The worker should wear an OSHA-approved N95 respirator mask when caring for a client with which of the following infectious diseases?
Select the best answer.
Explanation:
An OSHA-approved N95 respirator mask is recommended when caring for a client with tuberculosis due to the airborne transmission of the disease. Tuberculosis poses a higher risk of transmission via respiratory droplets, making respiratory protection essential to prevent exposure and infection among healthcare workers.
A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse. What nutrition information should the nurse include in the teaching?
Select the best answer.
Explanation:
While some of the other options may be helpful, the most appropriate advice for a client with COPD is to consume high-fiber foods to promote gastric emptying. Avoiding fluids just before and during meals can help prevent bloating, resting before meals can assist with dyspnea, and having several small meals a day can help reduce bloating. However, fibrous foods can lead to gas production, causing abdominal bloating and potentially worsening shortness of breath. Increasing calorie and protein intake is essential to prevent malnourishment. It is also important to avoid excessive carbohydrate intake, as it can increase carbon dioxide production and the risk of acidosis in COPD patients.
While dining at a restaurant, a person begins to choke. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
When encountering a choking individual, the nurse should first assess the person's ability to speak. If the person can speak, it indicates that their airway is partially obstructed, allowing some air to pass. In this case, encouraging the person to continue coughing and monitoring them closely may be appropriate. If the person cannot speak, it may suggest a complete airway obstruction and immediate intervention is required. Instructing the person to call 911 (Choice A) may be necessary if the situation worsens. Using the jaw-thrust maneuver (Choice C) is not appropriate for a choking victim. Performing abdominal thrusts (Choice D) is typically recommended for conscious choking victims, not chest compressions.
A client with chronic obstructive pulmonary disease (COPD) appears thin and disheveled. Which question should the nurse ask first?
Select the best answer.
Explanation:
In clients with severe COPD, shortness of breath can significantly impact their ability to perform basic activities like bathing and eating. Therefore, the nurse's priority should be to assess if shortness of breath is interfering with the client's basic activities, which can provide crucial information for planning and managing care.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
Select the best answer.
Explanation:
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
Select the best answer.
Explanation:
After a total hip replacement, clients should avoid bending at the waist past 90 degrees for at least 6 weeks to prevent dislocation of the hip prosthesis. Bending down to tie shoes involves significant hip flexion and should be avoided during the initial postoperative period to ensure proper healing and reduce the risk of complications.
A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)
Select the best answer.
Explanation:
Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.
A patient is assessing a client who has just been admitted to the emergency department. The client is having difficulty breathing and is using accessory muscles. What action by the nurse is best?
Select the best answer.
Explanation:
Placing the client in a high Fowler's position is the best action in this situation as it helps to maximize lung expansion, improve breathing, and decrease the work of breathing. This position allows for better chest expansion, improving oxygenation and ventilation for the client in respiratory distress.
What instruction should be included when teaching a client with asthma about using a metered-dose inhaler (MDI)?
Select the best answer.
Explanation:
Shaking the inhaler well before use ensures that the medication is properly mixed, allowing for an accurate dose with each administration. Inhaling slowly and deeply, not rapidly, helps the medication reach the lungs effectively. The medication should be administered while sitting or standing to facilitate proper lung expansion and airflow. Holding the inhaler 2 inches away from the mouth can lead to medication loss; it should be placed directly in the mouth or used with a spacer to optimize delivery to the airways.
A client had a total hip arthroplasty. Which of the following prescriptions should the nurse verify with the provider?
Select the best answer.
Explanation:
Following a total hip arthroplasty, the client should be instructed to restrict hip flexion past 90 degrees to prevent dislocation of the prosthesis. Restricting flexion past 120 degrees is excessive and could lead to complications. Therefore, the nurse should verify this prescription with the provider to ensure the client's safety and proper postoperative care.
During assessment, a healthcare provider is evaluating a client with chronic bronchitis. Which of the following percussion sounds should the healthcare provider expect?
Select the best answer.
Explanation:
In a client with chronic bronchitis, the nurse or healthcare provider would expect to hear resonant sounds upon percussion. Resonance is the normal percussion sound heard over healthy lung tissue. The other options such as dullness, tympany, and flatness are associated with different conditions or abnormalities, not typically expected in chronic bronchitis.
A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should not base her actions on which of the following information?
Select the best answer.
Explanation:
In an asthma action plan, the yellow zone indicates caution and signals a need to monitor symptoms closely. When a student is in the yellow zone, the appropriate action is to follow the prescribed steps, which typically include using a quick-relief inhaler and closely monitoring peak flow. Going to the hospital is usually reserved for severe asthma exacerbations in the red zone. Therefore, the information that the student needs to go to the hospital is not typically appropriate when the student is in the yellow zone.
A client has a three-chamber closed chest tube system, and the water seal chamber rises with client inspiration. What action should the nurse take?
Select the best answer.
Explanation:
In a client with a three-chamber closed chest tube system, a rise in the water seal chamber with client inspiration is an expected finding. The nurse should continue to monitor the client as this indicates that the system is functioning correctly. There is no need to notify the healthcare provider, reposition the client, or clamp the chest tube as these actions are not indicated in response to a rise in the water seal chamber.
A client is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching?
Select the best answer.
Explanation:
When a client is prescribed nicotine replacement therapy, it is crucial to emphasize that smoking while using this therapy can increase the risk of a stroke. Smoking while on nicotine replacement therapy can lead to excessive nicotine levels in the body, elevating cardiovascular risks. Therefore, the nurse should educate the client on the importance of avoiding smoking while utilizing this medication. Choices B, C, and D are not relevant to the specific teaching required for a client on nicotine replacement therapy.
A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
Select the best answer.
Explanation:
Seizure activity lasting longer than 5 minutes requires immediate intervention as it can lead to status epilepticus, a medical emergency.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
Select the best answer.
Explanation:
When caring for a client with burns, especially burns to the face and chest, the priority action for the nurse is to inspect the mouth for signs of inhalation injuries. Inhalation injuries can be life-threatening and may not be immediately apparent. Identifying these injuries early allows for prompt intervention and can significantly impact the client's outcomes. While other actions such as pain management and blood tests are important, assessing for inhalation injuries takes precedence due to its critical nature.
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