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 C

Explanation

A. Initiation of a high-sodium diet. A high-sodium diet is not indicated in pulmonary embolism management; it could worsen fluid retention and cardiovascular strain.

B. Application of a cast to the affected limb. Casting is not appropriate for pulmonary embolism, as it is not an orthopedic injury. Immobilization could increase the risk of further clot formation.

C. Administration of anticoagulant therapy. Anticoagulant therapy, such as heparin or warfarin, is the primary treatment for pulmonary embolism to prevent further clot formation and allow the body to dissolve the clot.

D. Administration of bronchodilators. Bronchodilators may alleviate respiratory symptoms but do not treat the underlying clot in pulmonary embolism. Anticoagulation remains the primary treatment.

A. Frequent urination B. Increased range of motion C. Localized bone pain and tenderness D. Hyperpigmentation of the skin

Correct Answer is C

Explanation

A. Frequent urination: Frequent urination is not associated with osteomyelitis, a bone infection.

B. Increased range of motion: Osteomyelitis typically causes pain and restricted movement, not increased range of motion.

C. Localized bone pain and tenderness: Osteomyelitis commonly presents with localized bone pain, tenderness, and possibly swelling due to infection.

D. Hyperpigmentation of the skin: Hyperpigmentation is not a typical sign of osteomyelitis.

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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

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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