A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

Elevation of the head of the bed by 30 degrees

Determining the amount of gasoline that the client encountered

Asking the client when they last ate a meal

Decontamination of the client

Answer and Explanation

The Correct Answer is D

A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.

B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.

C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.

D. Decontamination of the client

When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.

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Correct Answer is D

Explanation

A. Provide a heart-healthy low-potassium diet:

While a heart-healthy low-potassium diet is essential for managing chronic hyperkalemia and preventing future occurrences, it is not the first intervention to implement in a patient with a serum potassium level of 7.5 mEq/L and exhibiting cardiovascular changes. The effects of dietary changes on serum potassium levels are gradual and may take days to have a significant impact. In an acute situation like this, immediate interventions are needed to rapidly lower potassium levels and address the associated cardiovascular risks.

B. Prepare to administer sodium polystyrene sulfate 15g by mouth:

Sodium polystyrene sulfate is a medication used to exchange sodium for potassium in the gastrointestinal tract, effectively lowering serum potassium levels over hours to days. While it is a valid treatment for hyperkalemia, its onset of action is not immediate enough to address the urgent cardiovascular changes seen in severe hyperkalemia. Therefore, it is not the first-line intervention in this scenario.

C. Prepare the patient for hemodialysis treatment:

Hemodialysis is an effective method for rapidly lowering serum potassium levels in cases of severe hyperkalemia. However, it is a more invasive and time-consuming procedure that requires preparation, including vascular access and dialysis setup. It is typically reserved for situations where other interventions have failed or in patients with severe or refractory hyperkalemia. In the context of this scenario, where the patient has a serum potassium level of 7.5 mEq/L and is exhibiting cardiovascular changes, hemodialysis may be considered if initial interventions are not successful, but it is not the first action to implement.

A. Healthy middle-aged adult who never had chickenpox B. Older adult who lakes large doses of prednisone for a chronic condition C. Middle-aged adult who just started taking chemotherapy D. Nurse who recently received the first dose of varicella vaccine E. Young adult who is positive for the human immunodeficiency virus (HIV):

Correct Answer is ["B","C","E"]

Explanation

A. Healthy middle-aged adult who never had chickenpox:

This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.

B. Older adult who takes large doses of prednisone for a chronic condition:

Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.

C. Middle-aged adult who just started taking chemotherapy:

Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.

D. Nurse who recently received the first dose of varicella vaccine:

The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.

E. Young adult who is positive for the human immunodeficiency virus (HIV):

Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.

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A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?

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Naxlex Comprehensive Predictor Exams

A nurse cares for a patient who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which should the nurse implement first?

Correct Answer is D

Explanation

Which people have the greatest risk for serious complications secondary to herpes zoster infection? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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