A client returns from surgery with intermaxillary fixation following a fractured mandible.
The client suddenly becomes restless and begins gagging. What is the priority nursing action?
Cut the fixation wires immediately.
Position the client on their side and suction the airway.
Notify the provider of the client's condition.
Administer prescribed antiemetic medication.
The Correct Answer is B
Intermaxillary fixation involves wiring the jaws together, creating a significant airway risk if emesis occurs. Nursing knowledge must prioritize airway patency and the prevention of aspiration by using gravity and mechanical clearing before employing irreversible measures like wire cutting.
Choice A rationale
Cutting fixation wires is a rescue action if the airway cannot be cleared by other means. It should not be the first step because it compromises the surgical repair of the mandible and requires specific tools.
Choice B rationale
Side-lying positioning uses gravity to prevent emesis from entering the trachea, while suctioning clears the oropharynx. This immediate intervention maintains airway patency and prevents aspiration pneumonia in a client whose jaws are immobilized by wires.
Choice C rationale
Notifying the provider is necessary after the client is stabilized. During an acute gagging episode, the nurse must act independently to secure the airway before spending time communicating, as delay increases the risk of fatal aspiration.
Choice D rationale
Antiemetics are used for prevention but cannot treat an active gagging and vomiting episode. Administering medication takes too long to take effect and does not address the immediate physical obstruction of the airway by emesis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administering phenytoin requires applying knowledge of intravenous drug compatibility and cardiovascular safety profiles. The nurse must prioritize monitoring for life-threatening complications associated with rapid infusion, specifically focusing on the drug's narrow therapeutic index and its significant irritant properties.
Choice A rationale
Phenytoin is highly unstable and will precipitate if mixed with dextrose solutions. It must only be diluted with 0.9 percent sodium chloride. Incorrect dilution can lead to crystalline emboli and loss of drug efficacy during administration.
Choice B rationale
Intravenous phenytoin is a known vesicant that can cause purple glove syndrome if administered into small peripheral veins like those in the hand. Use of a large-bore catheter in a large vein or central line is preferred.
Choice C rationale
Rapid infusion of phenytoin can lead to severe cardiovascular collapse, including hypotension and fatal dysrhythmias. The infusion rate should not exceed 50 mg per minute to allow the heart to tolerate the drug's membrane-stabilizing effects safely.
Choice D rationale
The standard therapeutic range for phenytoin is 10 to 20 mcg per mL, not 20 to 30 mg per mL. Levels exceeding 20 mcg per mL often result in toxicity, characterized by nystagmus, ataxia, and decreased mental status.
Correct Answer is ["A","C","E","F"]
Explanation
The scenario requires applying principles of wound management, pain control, and infection prevention for thermal burns. Knowledge of tissue integrity, pharmacological intervention, and sterile surgical asepsis is necessary to prevent complications like syndactyly, infection, and severe pain during treatment.
Choice A rationale
Placing gauze between digits prevents skin surfaces from touching during healing. This essential intervention stops webbing or contractures, known as syndactyly, by maintaining anatomical separation of the fingers while absorbing exudate from the injured thermal burn sites.
Choice B rationale
Topical lotions containing vitamin E are inappropriate for acute thermal burns. Lotions can trap heat or introduce contaminants into open wounds. Specialized antimicrobial agents are required instead of over the counter moisturizers to ensure proper healing and safety.
Choice C rationale
Silver sulfadiazine is a broad spectrum topical antimicrobial used to prevent and treat wound sepsis in second and third degree burns. It effectively penetrates the eschar to reduce bacterial colonization, which is critical for successful skin regeneration.
Choice D rationale
Intact blisters serve as a natural sterile barrier against environment pathogens. Piercing or debriding small blisters increases the risk of infection and tissue trauma. Blisters should remain intact unless they interfere with joint movement or are significantly large.
Choice E rationale
Burn care and debridement are excruciatingly painful procedures. Administering systemic analgesics like morphine sulfate prior to care ensures the client reaches a therapeutic peak, which facilitates cooperation, reduces physiological stress, and manages severe pain during dressing changes.
Choice F rationale
Thermal burns destroy the primary skin barrier, leaving the client highly susceptible to healthcare associated infections. Strict sterile technique during wound care and dressing changes is mandatory to prevent sepsis and promote uncomplicated healing of the damaged tissues.
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