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?

Correct Answer: B

Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present. A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue. C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress. D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.

Correct Answer: C

Rationale: The correct answer is C: Tuberculosis. Healthcare workers should wear an N95 respirator mask when caring for clients with airborne infectious diseases like tuberculosis. The N95 mask is designed to filter out at least 95% of airborne particles, including those that may carry the tuberculosis bacteria. This level of protection is necessary to prevent the healthcare worker from inhaling the infectious agent. Pertussis (A), Mycoplasma pneumonia (B), and Respiratory syncytial virus (D) are not typically transmitted through the air and therefore do not require the use of an N95 respirator mask for standard care. These diseases are usually spread through respiratory droplets or direct contact, so standard precautions such as wearing a surgical mask and gloves are sufficient.

Correct Answer: C

Rationale: The correct answer is C: Smoking cessation. Chronic bronchitis is often caused by smoking. By quitting smoking, individuals can significantly reduce their risk of developing chronic bronchitis. This is the most effective prevention strategy. A: Maintenance of ideal weight may have some benefits for overall health but is not directly linked to preventing chronic bronchitis. B: Annual influenza immunization is important for preventing the flu, but it does not directly prevent chronic bronchitis. D: Regular moderate exercise is beneficial for overall health, but it is not as directly related to preventing chronic bronchitis as smoking cessation.

Correct Answer: A

Rationale: The correct answer is A: Fluctuation of the fluid level within the water seal chamber. This indicates proper chest tube function as it shows that the system is maintaining the desired pressure and allowing for adequate drainage without obstruction. When the patient breathes in and out, the fluid level fluctuates due to changes in intrathoracic pressure. Explanation of other choices: B: Absence of fluid in the drainage tubing - This would indicate a problem with drainage, possibly due to a blockage in the tubing. C: Continuous bubbling within the water seal chamber - This would suggest an air leak in the system, which is not ideal as it can lead to lung collapse. D: Equal amounts of fluid drainage in each collection chamber - While equal drainage is good, it does not specifically indicate proper chest tube function like the fluctuation of the fluid level does.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Provide straws and offer fluids between meals, which is suitable for delegation to a nursing assistant. This task involves assisting the client with fluid intake through a simple method that does not require clinical judgment or specialized training. Providing straws and offering fluids between meals can help the client increase their fluid intake, which is essential for addressing Deficient Fluid Volume. Option A) Administer IV fluids requires specialized training and the ability to assess the client's condition for any potential complications. This task falls under the scope of practice for licensed nurses and should not be delegated to a nursing assistant. Option C) Developing a plan for added fluid intake over 24 hours involves critical thinking and consideration of the client's specific needs, medical history, and overall condition. This task requires nursing judgment and should be performed by a licensed nurse. Option D) Teaching family members to assist the client with fluid intake involves providing education on the client's specific condition, signs of dehydration, and appropriate methods for encouraging fluid intake. This task requires healthcare knowledge and should be carried out by a healthcare provider with expertise in patient education. Educationally, understanding the principles of delegation in nursing practice is crucial for ensuring safe and effective patient care. Delegating tasks appropriately based on the complexity of the task, the competence of the individual, and the client's needs is essential in healthcare settings to optimize outcomes and promote quality care delivery.