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

Answer and Explanation

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 D

Explanation

A. Pain in the neck when the patient flexes their head towards the chest. This describes nuchal rigidity, not Kernig sign.

B. Involuntary flexion of the hips and knees when the neck is flexed. This describes Brudzinski sign, not Kernig sign.

C. Photophobia and headache triggered by bright light. These are symptoms of meningitis, but they are not specific to Kernig sign.

D. Pain and resistance when attempting to extend the patient's leg from a flexed position. A positive Kernig sign is when there is pain and resistance to leg extension from a flexed hip and knee position, indicating meningeal irritation.

A. Loss of pain temperature, and light touch sensation on the same side as the injury B. Loss of motor function and deep pressure sensation on the opposite side of the injury C. Loss of motor function and position sense on the same side as the injury D. Loss of motor function with preserved pain and temperature sensation in the lower extremities

Correct Answer is C

Explanation

A. Loss of pain, temperature, and light touch sensation on the same side as the injury. In Brown-Sequard syndrome, pain, temperature, and light touch are typically lost on the opposite (contralateral) side of the injury.

B. Loss of motor function and deep pressure sensation on the opposite side of the injury. Motor function and deep pressure sensation loss occur on the same side (ipsilateral) as the injury.

C. Loss of motor function and position sense on the same side as the injury. Brown-Sequard syndrome is a spinal cord hemisection injury leading to loss of motor function and proprioception on the same side as the injury.

D. Loss of motor function with preserved pain and temperature sensation in the lower extremities. Pain and temperature sensations are lost on the opposite side of the injury in Brown-Sequard syndrome, not preserved.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with suspected bacterial meningitis and notes a positive Kernig sign. How should the nurse interpret this finding?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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