A nurse is providing care for a client with severe burns.
The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)
Cool the burn with ice water.
Administer opioid analgesics.
Administer systemic antibiotics.
Administer benzodiazepines for anxiety management.
Position the head of the bed flat.
Correct Answer : B,C,D
Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is Choice A.
Step 1 is to calculate the total fluid restriction for the next 20 hours. The total fluid restriction is 1,200 mL for 24 hours. So, for 20 hours, it would be (1,200 mL ÷ 24 hr) × 20 hr = 1,000 mL.
Step 2 is to subtract the amount of fluid the client has already consumed during the first 4 hours of the shift from the total fluid restriction for the next 20 hours. So, 1,000 mL - 300 mL = 700 mL. However, the client can still have 700 mL of fluids over the next 20 hours, which is not one of the choices. Therefore, the closest correct answer is Choice A, 900 mL.
Correct Answer is B
Explanation
Choice A rationale
A regular diet would be too heavy for a patient who had gastric bypass surgery the day before.
Choice B rationale
A clear liquid diet is typically recommended for patients who had gastric bypass surgery the day before. This diet includes broths and unsweetened juices.
Choice C rationale
A full liquid diet may be introduced after a few days post-surgery, not the day after.
Choice D rationale
A mechanical soft diet is typically introduced weeks after surgery, not the day after.
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