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. Warfarin. Warfarin (Coumadin) is an anticoagulant used to prevent blood clots, but it typically requires several days to achieve a therapeutic effect and needs close monitoring of INR (International Normalized Ratio) levels. While it can be used for long-term prevention of DVT, it's not the immediate choice for post-operative prophylaxis.

B. Alteplase (tPA). Alteplase is a thrombolytic agent, used to break down existing clots, not prevent their formation. It is typically used in emergency situations, such as for treating ischemic stroke.

C. Clopidogrel. Clopidogrel is an antiplatelet agent, often used to prevent arterial clots, not DVTs. It is more commonly used in conditions like stroke and heart disease.

D. Enoxaparin. Enoxaparin, a low molecular weight heparin, is commonly used to prevent DVT after surgery by inhibiting specific clotting factors. It’s frequently prescribed for DVT prevention in orthopedic surgery patients.

A. Initiate intravenous fluid therapy B. Prepare the client for emergency surgery C. Administer high flow oxygen via a non-rebreather mask D. Apply sequential compression devices (SCDs)

Correct Answer is C

Explanation

A. Initiate intravenous fluid therapy. While fluid therapy is essential to support circulation and reduce the risk of shock, oxygenation takes priority in fat embolism management.

B. Prepare the client for emergency surgery. Surgery is not typically the first-line intervention for fat embolism; management focuses on supportive care, particularly respiratory support.

C. Administer high-flow oxygen via a non-rebreather mask. High-flow oxygen is the first priority to address hypoxia caused by fat embolism and should be administered immediately to maintain adequate oxygenation.

D. Apply sequential compression devices (SCDs). SCDs are used to prevent venous thromboembolism, but they do not help with the treatment of fat embolism.

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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

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