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 D
Explanation
A. Peripheral Artery Disease (PAD). PAD is a chronic condition related to reduced blood flow in peripheral arteries. It is not directly associated with MI complications.
B. Gastroesophageal Reflux Disease (GERD). GERD involves acid reflux and is not related to post-MI complications.
C. Hypertension. While hypertension is a risk factor for MI, it does not directly explain the symptoms of shortness of breath and irregular heartbeats following an MI.
D. Heart Failure. Heart failure is a common post-MI complication, especially if a significant portion of heart muscle is damaged. Symptoms of shortness of breath and irregular heartbeats could indicate left-sided heart failure, where fluid backs up into the lungs, or right-sided failure, which can lead to systemic congestion.
Correct Answer is C
Explanation
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.