The nurse is assessing a client with severe burn wounds. What are the nursing interventions performed by the nurse in the order
... [Show More] of priority?
Correct
⦁ Checking for a patent airway
Correct
⦁ Maintaining effective circulation
Correct
⦁ Performing adequate fluid replacement
Correct
⦁ Caring for the burn wound
A client is severely injured with burns and sustained major trauma from a fire incident. What is the order of assessments according to priority in this situation?
Correct
⦁ Using a jaw-thrust maneuver to establish an airway
Correct
2. Providing bag-valve-mask (BVM) ventilation
Correct
3. Palpating for the presence of a radial pulse
Correct
4. Monitoring systolic blood pressure
Correct
5. Assessing the score of eye opening
Correct
6. Removing the clothing with scissors
the eye opening, voice, and pain status. The clothes of the client are removed with scissors to prevent fabric melting into the skin.
The nurse is assessing a client with burns over 15% of the body. Which priority nursing action should be taken to ensure a complete assessment?
1 Determining the level of mobility
Correct2 Removing the clothes of the client
3 Placing the client in recumbent position
4 Cleaning the wounds with antiseptic solution
The nurse should remove all clothing of the client with scissors to allow for thorough assessment; this
A registered nurse teaches a new orienting nurse about interventions to be followed for a client with burns due to inhalation injury. Which statement made by the new orienting nurse indicates the new nurse needs more orientation?
1 "I should administer intravenous analgesia."
Correct2 "I should check pulses distal to burns."
3 "I should prepare for an endotracheal intubation."
4 "I should anticipate the need for fiberoptic bronchoscopy."
Inhalation injury burns occur in the nose, mouth, throat, and airway. The peripheral and central pulses are assessed, but they are not considered distal to the burn. The nurse should administer intravenous analgesia. The nurse should anticipate both endotracheal intubation and a need for fiberoptic bronchoscopy. [Show Less]