A nurse is providing first aid for a client who has a minor burn on one hand. Which of the following actions should the nurse take? (Select all that apply.)
Apply ice to the larger blisters.
Administer ibuprofen for pain.
Maintain skin integrity over the blisters.
Run cool water over the affected area.
Correct Answer : D,E
Running cool water over the affected area will help to decrease pain and prevent further tissue damage. Allowing the affected area to remain open to air will help to promote healing and prevent infection.
A. "Apply ice to the larger blisters" is an incorrect answer because applying ice can cause further damage to the skin and delay healing.
B. "Administer ibuprofen for pain" is an incorrect answer because the nurse cannot administer medications without a physician's order.
C. "Maintain skin integrity over the blisters" is an incorrect answer because maintaining skin integrity over the blisters can cause further damage and delay healing.
Explanation: The nurse should run cool water over the affected area and allow it to remain open to the air to promote healing and prevent infection. Applying ice or medication without a physician's order can cause further damage and delay healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D"]
Explanation
“Tachycardia” and “Irritability” are both symptoms that a nurse should expect to find when assessing an infant who is dehydrated in an emergency department.
Dehydration occurs when an infant loses so much body fluid that they are not able to maintain ordinary function.
Tachycardia, or a fast heart rate, is a common sign of dehydration in babies and toddlers.
Irritability is also a common sign of dehydration in newborns.
Choice B is not an answer because bloating is not a common symptom of dehydration in infants.
Choice C is not an answer because hypertension, or high blood pressure, is not a
common symptom of dehydration in infants.
Correct Answer is A
Explanation
Fluid overload is a potential complication of blood transfusion, and dyspnea is one of the hallmarks of fluid overload. Other signs and symptoms of fluid overload include a headache, hypertension, jugular vein distention, rapid breathing, and tachycardia.
An explanation for incorrect choices:
B. Fever is generally not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a febrile non-hemolytic transfusion reaction.
C. Pruritus is typically not associated with fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as an allergic reaction.
D. Bradycardia is not typically associatedwith fluid overload but can be a sign of an adverse reaction to the blood transfusion, such as a hemolytic transfusion reaction.
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