HESI RN Exit VI Proctored Exam
While the nurse is admitting a client with partial thickness burns to the upper extremities, chest, and abdomen, the client experiences difficulty swallowing. The client is drooling and anxious. Which intervention should the nurse implement first?
Explanation & Rationale
A. Assessing papillary reactions to light is important in a neurological assessment but is not the priority in this situation.B. Measuring and recording abdominal girth is not relevant to the client's current symptoms.C. Auscultating over the main stem bronchus is the priority action as the client's symptoms suggest potential airway compromise, possibly from inhalation injury or swelling. Early identification and management of airway issues are critical in burn patients.D. Determining the time of last oral intake is part of a comprehensive assessment but is not the immediate priority when airway compromise is suspected.
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