A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)
Submerge client in a cold bath
Administer oxygen
Restrict fluids
Provide a meal high in fiber
Assess airway
Apply ice to burned areas
Correct Answer : E,F
Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.
Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.
Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.
Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.
Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.

Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason: The client needs total nursing care is the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which is a tool that measures the level of consciousness based on eye opening, verbal response, and motor response. A score of 6 indicates severe brain injury and coma, meaning that the client is unresponsive and dependent on others for all activities of daily living.
Choice B Reason: Indicates stable neurologic status is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A stable neurologic status means that there are no changes in the level of consciousness, vital signs, or neurological signs.
Choice C Reason: The client has a decline in level of consciousness but is able to protect his airway is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. A decline in level of consciousness means that the client is less alert and responsive than normal, but still able to respond to stimuli and maintain airway patency.
Choice D Reason: The client is alert and oriented is not the expected outcome for a client who has a score of 6 on the Glasgow Coma Scale, which indicates severe brain injury and coma. Alert and oriented means that the client is fully awake and aware of person, place, time, and situation.
Correct Answer is B
Explanation
Choice A Reason: Hemorrhage is not a complication of an acute spinal cord injury, but rather a possible cause of it. Hemorrhage can occur due to trauma or rupture of blood vessels in or around the spinal cord, leading to compression and damage of the nerve tissue.
Choice B Reason: This is the correct choice. Spinal shock is a complication of an acute spinal cord injury that occurs within minutes to hours after the injury. It is characterized by loss of sensation, motor function, reflexes, and autonomic function below the level of injury. It is caused by transient disruption of nerve conduction and synaptic transmission in the spinal cord.
Choice C Reason: Apoptosis is not a complication of an acute spinal cord injury, but rather a cellular process that occurs after it. Apoptosis is programmed cell death that occurs in response to injury or stress. It can lead to further loss of neurons and glial cells in the spinal cord over time.
Choice D Reason: Neurogenic shock is a complication of an acute spinal cord injury that occurs within hours to days after the injury. It is characterized by hypotension, bradycardia, and peripheral vasodilation due to loss of sympathetic tone and unopposed parasympathetic activity. It is caused by disruption of autonomic pathways in the spinal cord.

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
