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 C
Explanation
A. Initiate intravenous fluid therapy. While fluid therapy is essential to support circulation and reduce the risk of shock, oxygenation takes priority in fat embolism management.
B. Prepare the client for emergency surgery. Surgery is not typically the first-line intervention for fat embolism; management focuses on supportive care, particularly respiratory support.
C. Administer high-flow oxygen via a non-rebreather mask. High-flow oxygen is the first priority to address hypoxia caused by fat embolism and should be administered immediately to maintain adequate oxygenation.
D. Apply sequential compression devices (SCDs). SCDs are used to prevent venous thromboembolism, but they do not help with the treatment of fat embolism.
Correct Answer is D
Explanation
A. Irritable bowel syndrome. IBS management typically involves dietary changes, fiber, and stress management, not antibiotics or clear liquids.
B. Chronic diverticulosis. Diverticulosis, when asymptomatic, does not require antibiotics. Treatment focuses on a high-fiber diet to prevent diverticulitis.
C. Complicated diverticulitis with abscess. Complicated diverticulitis may require IV antibiotics, hospitalization, or even surgical intervention if there are abscesses.
D. Uncomplicated diverticulitis. Uncomplicated diverticulitis, without abscess or perforation, is treated with oral antibiotics and a clear liquid diet for bowel rest.