HESI Registered Nurse EXIT Practice Exam

When caring for a client with first and second degree burns on the face, neck, anterior chest, and hands, what should the nurse prioritize?

1. Cover the areas with dry sterile dressings

2. Assess for dyspnea or stridor

3. Initiate intravenous therapy

4. Administer pain medication

The correct answer is: Assess for dyspnea or stridor

Prioritizing the assessment for dyspnea or stridor is crucial in this scenario because burns on the face, neck, and anterior chest can potentially compromise the airway. First and second-degree burns in these areas increase the risk for facial swelling, which can occur rapidly and lead to airway obstruction. Stridor, a high-pitched wheezing sound indicating airway narrowing, is a critical sign that patients may be developing respiratory distress. Monitoring for signs of airway compromise should be the nurse's first action. If any respiratory distress is evident or if the patient exhibits dyspnea or stridor, it can indicate that immediate intervention is necessary to secure the airway, such as preparing for intubation or other advanced airway management. While the other actions, such as covering the burns, initiating IV therapy, and administering pain medication, are important components of burn care, they do not take precedence over ensuring that the airway is protected in a client presenting with potential respiratory risks. Addressing airway concerns is fundamental to preventing complications that could quickly become life-threatening.