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 B

Explanation

A. Administer high-calorie diet to prevent weight loss. While adequate nutrition is important, a high-calorie diet is not the primary priority in managing heart failure. Sodium and fluid management are usually more crucial to control fluid overload.

B. Reduce sodium intake to help manage fluid retention. Reducing sodium intake is a priority in heart failure management as it helps prevent fluid retention, which reduces workload on the heart and decreases symptoms of fluid overload.

C. Encourage complete bed rest to reduce cardiac workload. Complete bed rest is not recommended as it can lead to deconditioning and increased risk of blood clots. Activity should be balanced according to the patient’s tolerance.

D. Increase fluid intake to maintain hydration. In heart failure, increasing fluid intake could worsen fluid overload. Fluid restriction may be necessary to prevent excess fluid retention.

A. A clean catch urinalysis and urine culture B. Foley catheter placement C. Broad-spectrum antibiotic D. 0.9% sodium chloride infusion at 100 ml/hr E. WBC count F. Blood cultures × 2

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

Explanation

A. A clean catch urinalysis and urine culture: A urinalysis and culture are essential to identify the presence of infection, type of bacteria, and appropriate antibiotic sensitivity.

B. Foley catheter placement: Foley catheters are not routinely indicated for suspected urinary tract infections (UTIs) unless there is an issue with urinary retention or other specific medical indication.

C. Broad-spectrum antibiotic: Initiating a broad-spectrum antibiotic may be appropriate while waiting for culture results to address infection.

D. 0.9% sodium chloride infusion at 100 ml/hr: IV fluids are not typically necessary for a UTI unless the patient is dehydrated or unable to take oral fluids.

E. WBC count: A WBC count can help assess the systemic inflammatory response and gauge the severity of the infection.

F. Blood cultures × 2: Blood cultures are generally reserved for cases where a systemic infection or sepsis is suspected, which is not indicated by this patient's symptoms alone.

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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 caring for a patient with heart failure. Which of the following treatment goals should the nurse prioritize?

Correct Answer is B

Explanation

A nurse is caring for a client in a clinic who has foul, smelling urine, a low-grade fever of 37.7° C (100° F), and pain with urination. Which of the following should the nurse expect the health care provider to order?

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

Explanation

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