The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?
Elevate the extremity and apply an ice pack to the injured area
Contact poison control to determine the best neutralizing agent
Apply a sterile dressing, wrapping the fingers separately
Irrigate the affected area with room temperature water
The Correct Answer is D
A. Elevate the extremity and apply an ice pack to the injured area
Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.
B. Contact poison control to determine the best neutralizing agent
While contacting poison control is important, it should not be the immediate first action in an emergency setting.
C. Apply a sterile dressing, wrapping the fingers separately
This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.
D. Irrigate the affected area with room temperature water
Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Fluid resuscitation
Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.
B. Transfer to a burn center
While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.
C. Application of sterile dressings
Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.
D. Administer morphine 8 mg IV
Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.
Correct Answer is C
Explanation
A. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.
B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.
C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.
D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.
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