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 B
Explanation
A. Keep the patient NPO (nothing by mouth) until the T-tube is removed. Patients are generally kept NPO initially but may resume clear liquids and progress to a regular diet based on tolerance; NPO status is not required until the T-tube is removed.
B. Monitor the tube drainage and document the amount and color. Monitoring and documenting drainage from the T-tube is crucial to assess biliary function and ensure that the bile is draining properly, indicating no obstruction.
C. Ensure the tube is clamped for 8 hours each day. Clamping may be done before tube removal to test the body’s tolerance to bile drainage, but it should be done only as per physician orders, not routinely for 8 hours each day.
D. Flush the T-tube with normal saline every 4 hours. Flushing a T-tube is generally not done routinely as it could disrupt the flow of bile and cause complications.
Correct Answer is C
Explanation
A. Initiation of a high-sodium diet. A high-sodium diet is not indicated in pulmonary embolism management; it could worsen fluid retention and cardiovascular strain.
B. Application of a cast to the affected limb. Casting is not appropriate for pulmonary embolism, as it is not an orthopedic injury. Immobilization could increase the risk of further clot formation.
C. Administration of anticoagulant therapy. Anticoagulant therapy, such as heparin or warfarin, is the primary treatment for pulmonary embolism to prevent further clot formation and allow the body to dissolve the clot.
D. Administration of bronchodilators. Bronchodilators may alleviate respiratory symptoms but do not treat the underlying clot in pulmonary embolism. Anticoagulation remains the primary treatment.