A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
a. Assess the level of consciousness and pupillary reactions.
b. Ascertain the time food or liquid was last consumed.
c. Auscultate breath sounds over the trachea and bronchi.
d. Measure abdominal girth and auscultate bowel sounds.
ANS: C
Inhalation injuries are present in 7% of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.
You might also like to view...
Which statement is consistent with societal views of dying in the United States?
a. Dying is viewed as a failure on the part of the system and providers. b. Most Americans would prefer to die in a hospital to spare loved ones the burden of care. c. People die of indistinct, complex illness for which a cure is always possible. d. The purpose of the healthcare system is to prevent disease and treat symptoms.
It is important to monitor and track unintended consequences of health IT implementation because:
a. reporting is mandatory. b. not much is known and we need to learn more. c. the federal government is interested in this information. d. this is a prevalent issue.
A patient in a clinical research study has given informed consent. This means that the patient has certain rights. These rights include which of the following? Select all that apply
A) confidentiality B) free medical care C) refusal to participate D) protection from harm E) guarantee of treatment F) consent knowledgeably
A family member receives Medicaid. Which is most likely to limit access of this person to healthcare?
A) Inability to find a provider who accepts Medicaid B) Pre-existing conditions C) Lack of insurance D) Large insurance premiums