Burns: Initial Resuscitation Priorities Practice Test

A 62-year-old client (history: atrial fibrillation on anticoagulation) arrives after an electrical injury with burns on the right hand and scalp; the client briefly lost consciousness at the scene. Vital signs: T 36.6°C (97.9°F), HR 132/min and irregular, RR 20/min, BP 98/60 mm Hg, SpO2 97% on room air. What is the first action the nurse should take upon assessing the client?

A 26-year-old client (history: none) is admitted after an electrical injury with a small burn on the palm and a burn on the heel; the client is alert but reports muscle pain. Vital signs: T 37.1°C (98.8°F), HR 110/min, RR 18/min, BP 118/70 mm Hg, SpO2 99% on room air. Which finding requires immediate intervention by the nurse during initial resuscitation?