A client presents to the emergency department following a chemical burn from an industrial solvent. What is the nurse's priority intervention?

Initiate running water irrigation of the affected area.

Administer liberal oral fluids to maintain hydration.

Cover the burn with a sterile dressing immediately.

Perform a pain assessment and administer analgesics.

Answer and Explanation

The Correct Answer is A

Chemical burns from industrial solvents require immediate intervention to prevent ongoing tissue damage caused by continued chemical reaction with the skin. Unlike thermal burns, chemical agents may continue to destroy tissue until they are adequately removed or diluted. Emergency management focuses on rapid decontamination to limit depth of injury and systemic absorption of the chemical. Prompt irrigation is the most critical first action in reducing further harm.

Rationale:
A. Initiating running water irrigation of the affected area is the priority intervention because it rapidly dilutes and removes the chemical agent from the skin. Continuous flushing helps stop the ongoing tissue destruction caused by the industrial solvent. Early decontamination significantly reduces burn depth, systemic absorption, and long-term complications.

B. Administering liberal oral fluids may be important later for hydration support, but it does not address the immediate chemical injury. The primary concern in chemical burns is stopping ongoing tissue damage at the site of exposure. Fluid administration becomes secondary after decontamination and stabilization of the burn area.

C. Covering the burn with a sterile dressing immediately is not the priority because it may trap the chemical agent against the skin. This can prolong exposure and worsen tissue damage if decontamination has not been completed. Dressing application is only appropriate after thorough irrigation and removal of the chemical substance.

D. Performing a pain assessment and administering analgesics is important in burn management but is not the first priority in chemical burns. Ongoing tissue destruction must be stopped before focusing on comfort measures. Analgesia is provided after initial decontamination to ensure the underlying cause of pain has been addressed.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Preventive nursing education for travel-associated gastrointestinal infections is vital for patients with history of travel. The client presents with symptoms consistent with infectious gastroenteritis (Traveler’s Diarrhea) likely acquired during recent international travel, including diarrhea, nausea, and mild dehydration. Preventive teaching aims to reduce exposure to contaminated food, water, and pathogens. Key interventions include hygiene practices, safe food handling, and appropriate immunizations, while behaviors that increase infection transmission risk are contraindicated.

Rationale:

• Educate on safe water and food preparation: Contaminated food and water are major sources of travel-related gastrointestinal infections. Teaching safe practices such as drinking bottled or treated water and avoiding raw or undercooked foods helps prevent recurrence. These interventions directly reduce exposure to common pathogens like bacteria, viruses, and parasites. Therefore, this is an essential preventive measure.

• Promote hand hygiene before meals: Hand hygiene is one of the most effective ways to prevent transmission of infectious organisms. Proper handwashing reduces fecal-oral transmission of pathogens commonly responsible for traveler’s diarrhea. Encouraging this behavior helps interrupt infection spread. It is a fundamental preventive strategy.

• Advise vaccination for travelers: Vaccination can prevent specific travel-related infections depending on destination, such as hepatitis A or typhoid fever. Pre-travel immunization reduces the risk of acquiring preventable gastrointestinal infections. This is an important component of travel health preparation. It is a standard preventive recommendation.

• Encourage sharing of personal utensils: Sharing personal utensils increases the risk of transmitting infectious organisms between individuals. Gastrointestinal infections are often spread via contaminated surfaces and oral-fecal routes. Promoting shared utensil use directly contradicts infection prevention principles.

A. Tyler Impert, who reports pain in his calf and has localized redness of the area. B. Helder Valladares, who requested pain medication that has not yet been administered. C. Allyn Pennant, who has an infiltrated IV line and has an IV medication scheduled. D. David Francois, who requested assistance to the bathroom and an AP was notified.

Correct Answer is A

Explanation

Prioritization in nursing requires identifying clients at highest risk for life-threatening conditions first. Acute changes suggesting impaired circulation or thromboembolic events take precedence over routine care needs such as pain management or assistance with activities of daily living. Clinical signs such as unilateral calf pain and localized redness may indicate deep vein thrombosis (DVT), which carries a risk of pulmonary embolism if not promptly addressed. Rapid assessment and intervention are essential to prevent complications.

Rationale:
A. Tyler Impert’s presentation of calf pain and localized redness is highly concerning for deep vein thrombosis (DVT). This condition can progress to pulmonary embolism, which is life-threatening if a clot dislodges and travels to the lungs. Early assessment allows for immediate diagnostic testing and initiation of anticoagulation therapy if confirmed, making this the highest priority client.

B. Helder Valladares requesting pain medication that has not yet been administered is a comfort issue rather than an immediate life-threatening condition. While timely pain management is important, it does not take priority over potential vascular emergencies. Pain control can be addressed after evaluating more critical clients.

C. Allyn Pennant with an infiltrated IV line requires prompt attention, especially since IV medication is scheduled; however, infiltration is generally a localized complication. It may cause discomfort or tissue irritation but is not immediately life-threatening. The IV can be restarted after more urgent assessments are completed.

D. David Francois requesting assistance to the bathroom represents a routine safety and mobility need. While fall prevention is important, this situation does not indicate an acute or emergent condition. Assistance can be delegated to assistive personnel after the nurse addresses higher-priority clients.

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A client presents to the emergency department following a chemical burn from an industrial solvent. What is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}

Explanation

Based on the change of shift report, which client should the nurse assess first?

Correct Answer is A

Explanation

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