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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View Related questions
Correct Answer is D
Explanation
A. I need to monitor the puncture site for signs of infection such as redness or swelling. Monitoring the puncture site is crucial for detecting any signs of infection or complications, which the patient should be aware of.
B. I should follow a heart-healthy diet to support my recovery. A heart-healthy diet is recommended to manage cholesterol levels and prevent further coronary artery disease progression.
C. I will take my prescribed medications as directed by my doctor. Following the medication regimen is important for preventing complications and supporting recovery, especially for blood thinners or other cardiac medications.
D. I can resume my regular physical activities immediately after I get home. This statement indicates a need for further teaching, as patients should gradually resume physical activities and avoid strenuous activities immediately after PTCA to prevent complications, such as bleeding at the catheter insertion site.
Correct Answer is ["A","C","D","E"]
Explanation
A. Ensure that the client's urine output is at least 1 ml/kg/hr. Adequate urine output is essential before administering IV potassium to ensure the kidneys are functioning properly and can handle the increased potassium load, preventing hyperkalemia.
B. Ensure potassium infusion is prepared with 5% dextrose solution. While IV potassium can be mixed with normal saline or dextrose solutions, the specific diluent will depend on the clinical scenario. This isn't necessarily a standard requirement, so it may not be appropriate for all situations.
C. Educate the client regarding high-potassium foods. Education on high-potassium foods helps the client maintain potassium levels after treatment, reducing the need for future supplementation.
D. Repeat blood serum potassium levels. Rechecking potassium levels ensures the patient reaches a safe and therapeutic range and helps monitor for signs of overcorrection or continued hypokalemia.
E. Cardiac monitoring during infusion. Cardiac monitoring is critical, as hypokalemia and potassium replacement can affect heart rhythm and lead to arrhythmias.