A patient seeking treatment after being in a house fire has thermal burns to the neck and shoulders and singed nasal hairs. Which action should the nurse take first?
a. Monitor respirations.
b. Monitor urine output.
c. Obtain blood pressure.
d. Place the patient in a private room.
ANS: A
Continuous assessment of respiratory status is essential for burns or soot on the face, singed nasal hairs, a hoarse voice, coughing, or restlessness. B. Urine output can be determined at a later time. C. Blood pressure would be determined after the patient's airway and breathing are established. D. There is no reason to place the patient in a private room.
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