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

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. Conjunctivitis. Conjunctivitis generally presents with redness and discharge but does not cause elevated intraocular pressure, severe pain, or visual disturbances like halos.

B. Acute angle-closure glaucoma. Acute angle-closure glaucoma is characterized by sudden severe eye pain, blurred vision, halos around lights, nausea, and vomiting, along with elevated intraocular pressure and a cloudy cornea.

C. Retinal detachment. Retinal detachment may cause sudden vision loss or flashing lights but typically lacks pain, nausea, or vomiting, and does not affect intraocular pressure.

D. Migraine with aura. A migraine with aura may cause visual disturbances but does not present with eye pain, red eye, or elevated intraocular pressure.

A. Share personal items like razors and toothbrushes. B. Drink alcohol in moderation to avoid liver strain. C. Wash your hands thoroughly after using the bathroom. D. Avoid all physical activities to conserve energy

Correct Answer is C

Explanation

A. Share personal items like razors and toothbrushes. Sharing personal items that may come in contact with blood or body fluids, like razors and toothbrushes, increases the risk of spreading hepatitis, so clients should avoid sharing these items.

B. Drink alcohol in moderation to avoid liver strain. Clients with hepatitis should avoid alcohol entirely, as alcohol can worsen liver inflammation and damage, which would strain the liver further.

C. Wash your hands thoroughly after using the bathroom. Hand hygiene is crucial, especially for hepatitis A, which can spread through fecal-oral transmission. Washing hands can prevent the spread of the virus to others.

D. Avoid all physical activities to conserve energy. Although clients may need to rest, they do not need to avoid all physical activity. Light, tolerated activity can help maintain strength and prevent complications from immobility.

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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?

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Correct Answer is B

Explanation

The nurse is providing home care instructions to a client with hepatitis. Which of the following should be included in the teaching?

Correct Answer is C

Explanation

A client presents the emergency department with a Grade II ankle sprain. Which of the following interventions should the nurse implement?

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