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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Stroke: The sudden onset of one-sided weakness, numbness, difficulty speaking, and severe headache are classic symptoms of an acute stroke, where blood flow to part of the brain is interrupted, leading to neurological deficits.
B. Migraine: While migraines can cause headache and some neurological symptoms, they usually include visual disturbances, nausea, or photophobia rather than one-sided weakness and numbness.
C. Hypoglycemia: Hypoglycemia can cause confusion, weakness, and headache, but it typically lacks the focal neurological symptoms, like one-sided weakness and numbness.
D. Transient Ischemic Attack (TIA): A TIA can cause similar symptoms, but the deficits are usually transient and resolve within 24 hours without lasting neurological damage. Persistent symptoms are more indicative of a stroke.
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