A nurse is caring for a client who sustained burns in an enclosed space and is exhibiting singed nasal hair, black sputum and smoky smelling breath. What is the nurse’s priority intervention?
Administering pain medication
Applying a cool, wet cloth to burned areas.
Administering high flow oxygen via a non-rebreather mask
Initiating intravenous fluid resuscitation
The Correct Answer is C
A. Administering pain medication: Pain management is essential, but in this case, the primary concern is potential airway compromise due to inhalation injury, which should be addressed first.
B. Applying a cool, wet cloth to burned areas: Cooling burned areas can help with pain and reduce burn severity but is not the priority in a case of suspected inhalation injury with airway compromise.
C. Administering high-flow oxygen via a non-rebreather mask: This client is at high risk for respiratory compromise due to inhalation injury; administering high-flow oxygen is the priority to ensure adequate oxygenation.
D. Initiating intravenous fluid resuscitation: Fluid resuscitation is essential for burn patients but is not the immediate priority over addressing potential airway and oxygenation issues.
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Correct Answer is A
Explanation
A. Consume small frequent meals throughout the day. Small, frequent meals reduce the volume of food entering the small intestine at one time, helping to prevent symptoms of dumping syndrome.
B. Lie down immediately after eating to aid digestion. Although lying down after eating can slow gastric emptying and help prevent dumping syndrome, it does not aid in digestion.
C. Include high-carbohydrate foods in every meal. High-carbohydrate foods are likely to worsen symptoms of dumping syndrome by causing rapid glucose absorption, which leads to a spike in insulin and subsequent hypoglycemia.
D. Drink fluids with meals to aid in digestion. Fluids should be taken between meals rather than with meals to avoid rapid gastric emptying and prevent dumping syndrome.
Correct Answer is D
Explanation
A. Include high-fat foods to maintain weight. High-fat foods can worsen symptoms in ulcerative colitis by increasing bowel irritation and causing malabsorption. A balanced diet that is low in fat is usually recommended.
B. Eat three large meals a day to ensure adequate nutrition. Large meals can increase digestive workload and exacerbate symptoms. Smaller, more frequent meals are generally better tolerated.
C. Increase intake of dairy products to boost calcium levels. Many patients with ulcerative colitis are lactose intolerant or sensitive to dairy, which can worsen symptoms. Calcium can be obtained from other sources if needed.
D. Consume a low-fiber diet to minimize bowel irritation. A low-fiber diet can reduce mechanical irritation in the bowel, which is beneficial during flare-ups of ulcerative colitis.