A patient with chemical burns to the chest and abdomen is admitted to the emergency department.
The registered nurse begins to flush the area with sterile saline.
What is the first action the LPN should take to stop the burning process?
Prepare IV morphine for administration by the RN.
Apply ice to the burned area.
Apply a neutralizing agent.
Remove the patient’s clothing.
The Correct Answer is D
Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Informing the charge nurse is an important step, but it is not the immediate action. The nurse should first assess the situation before escalating it.
Choice B rationale
Applying a dressing under the client’s nose might help manage the drainage, but it does not address the underlying issue. The drainage could be cerebrospinal fluid (CSF), which is a serious condition that needs immediate attention.
Choice C rationale
Checking the client’s temperature is a general assessment and does not directly relate to the symptom of clear nasal drainage.
Choice D rationale
Testing the drainage for glucose is the correct action. Clear nasal drainage after a basal skull fracture could be a sign of a cerebrospinal fluid (CSF) leak. CSF contains glucose, so testing the drainage for glucose can help confirm if it’s CSF34.
Correct Answer is B
Explanation
Choice A rationale
Maintaining the client on bed rest is not a recommended intervention for a client with urolithiasis. Bed rest does not facilitate the passage of stones and can lead to complications such as deep vein thrombosis.
Choice B rationale
Encouraging the client to drink 3 L of fluids per day is the correct intervention. Increased fluid intake can help flush out the urinary system and facilitate the passage of stones. It also helps prevent new stone formation by diluting the substances that lead to stones.
Choice C rationale
Providing the client a high protein diet is not a recommended intervention for a client with urolithiasis. High protein diets can increase the amount of calcium and uric acid in urine, which can contribute to stone formation.
Choice D rationale
Telling the client to expect a decrease in urine output is not a recommended intervention for a client with urolithiasis. Decreased urine output can lead to urinary stasis and contribute to stone formation.
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