A client is brought to the emergency department with partial-thickness burns to his face, neck, arms, and chest after trying to put out a car fire. The nurse should implement which nursing actions for this client? (Select all that apply.)
Submerge client in a cold bath
Administer oxygen
Restrict fluids
Provide a meal high in fiber
Assess airway
Apply ice to burned areas
Correct Answer : E,F
Choice A Reason: This is incorrect because submerging the client in a cold bath can cause hypothermia, shock, or infection. Cold water can lower the body temperature and blood pressure, which can impair circulation and organ function. Cold water can also introduce bacteria or contaminants into the open wounds. The nurse should use cool water or saline to gently irrigate the burned areas and then cover them with sterile dressings.
Choice B Reason: This is correct because administering oxygen can help the client breathe better and prevent hypoxia. Burns to the face, neck, or chest can cause swelling or damage to the airway, which can impair gas exchange and oxygen delivery. Oxygen can also reduce the risk of carbon monoxide poisoning, which can occur from inhaling smoke or fumes.
Choice C Reason: This is incorrect because restricting fluids can worsen dehydration and shock. Burns can cause significant fluid and electrolyte loss through evaporation and leakage from damaged capillaries. This can lead to hypovolemia, which is low blood volume, and hypotension, which is low blood pressure. The nurse should monitor the client's vital signs, urine output, and weight, and administer intravenous fluids as ordered.
Choice D Reason: This is incorrect because providing a meal high in fiber can cause abdominal discomfort or diarrhea. Burns can cause paralytic ileus, which is a temporary loss of bowel function due to nerve damage or inflammation. This can impair digestion and absorption of food and cause nausea, vomiting, or constipation. The nurse should assess the client's bowel sounds and provide enteral or parenteral nutrition as ordered.
Choice E Reason: This is correct because assessing airway is a priority nursing action for a client with burns. As mentioned above, burns to the face, neck, or chest can compromise the airway and cause respiratory distress or failure. The nurse should assess the client's level of consciousness, breathing rate and pattern, oxygen saturation, and signs of inhalation injury, such as sooty sputum, singed nasal hairs, or hoarseness. The nurse should also be prepared to assist with intubation or tracheostomy if needed.
Choice F Reason: This is correct because applying ice to burned areas can help reduce pain and swelling. Ice can constrict blood vessels and numb nerve endings, which can decrease inflammation and sensation. However, ice should be applied for no more than 15 minutes at a time and wrapped in a cloth or towel to prevent frostbite or tissue damage. Ice should not be applied to large or deep burns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason: Head trauma is not one of the top causes of blindness in the United States, but rather a possible cause of it. Head trauma can damage the optic nerve, retina, or brain, leading to vision loss or impairment.
Choice B Reason: Cardiovascular disease is not one of the top causes of blindness in the United States, but rather a risk factor for it. Cardiovascular disease can affect the blood supply and oxygen delivery to the eyes, leading to conditions such as glaucoma, macular degeneration, or retinal vein occlusion.
Choice C Reason: Syphilis is not one of the top causes of blindness in the United States, but rather a rare cause of it. Syphilis is a sexually transmitted infection that can affect the eyes, leading to inflammation, scarring, or detachment of the retina.
Choice D Reason: This is the correct choice. Diabetic retinopathy is one of the top causes of blindness in the United States, affecting about 4.1 million adults. Diabetic retinopathy is a complication of diabetes that damages the blood vessels in the retina, leading to bleeding, swelling, or leakage of fluid. It can cause blurred vision, floaters, or blindness if left untreated.
Correct Answer is C
Explanation
Choice A Reason: Obtaining the client's blood glucose every 12 hr is not enough, as the nurse should monitor it more frequently, at least every 4 to 6 hr, to prevent hyperglycemia or hypoglycemia. TPN is a high-glucose solution that can affect the blood sugar levels.
Choice B Reason: Changing the IV site dressing every 4 days is not enough, as the nurse should change it daily or as needed to prevent infection. TPN is a high-risk solution that can introduce microorganisms into the bloodstream.
Choice C Reason: This is the correct choice. Changing the IV tubing every 24 hr is recommended to prevent infection and maintain sterility. TPN is a complex solution that can support bacterial growth and contamination.
Choice D Reason: Weighing the client every other day is not enough, as the nurse should weigh the client daily to evaluate fluid balance and nutritional status. TPN can cause fluid retention or depletion, as well as weight gain or loss.
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