A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

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Question 1 of 4

A nurse in the emergency department is caring for a client who has full-thickness burns of the thorax and upper torso. After securing the client's airway, which of the following is the nurse's priority intervention?

Correct Answer: D

Rationale: After securing the airway, initiating IV fluids is the priority to prevent hypovolemic shock in clients with severe burns. IV fluids help maintain circulating volume and prevent a drop in blood pressure due to fluid loss. Providing pain management, offering emotional support, and preventing infection are important aspects of care but are secondary to ensuring adequate fluid resuscitation in clients with severe burns.

Question 2 of 4

A client has a new diagnosis of Raynaud's disease. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: The correct answer is to keep the home environment warm. Raynaud's disease causes vasospasm in response to cold, so maintaining a warm environment can help prevent attacks. Choices A, C, and D are incorrect. Increasing potassium intake, elevating legs when sitting, or reducing sodium intake are not specific to managing Raynaud's disease.

Question 3 of 4

A nurse is caring for a client who is 2 hours postoperative following a colon resection. Which of the following assessments is the nurse's priority?

Correct Answer: D

Rationale: The correct answer is D: Oxygen saturation. The priority assessment in this situation is oxygen saturation because postoperative clients are at risk for respiratory complications, such as hypoxia due to factors like anesthesia effects, impaired lung function, or pain interfering with deep breathing. Monitoring oxygen saturation is crucial to detect any respiratory compromise early. Capillary refill, bowel sounds, and temperature are important assessments but are not the priority in this immediate postoperative period.

Question 4 of 4

A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take?

Correct Answer: B

Rationale: The correct action for the nurse to take when caring for a client with schizophrenia experiencing auditory hallucinations is to ask the client directly what they are hearing. This approach helps the nurse gain insight into the client's experience, establish effective communication, and provide appropriate support. Encouraging the client to lie down in a quiet room (Choice A) may not address the hallucinations directly. Telling the client that the voices are not real (Choice C) can be invalidating and may lead to further distress. Providing headphones for music (Choice D) may not be effective in addressing the client's hallucinations.

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