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.

Allow the affected area to remain open to air.

Answer and Explanation

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.

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Correct Answer is A

Explanation

The correct answer is choice A. Auscultate the client's abdomen for bowel sounds. This is the first action the nurse should take because it provides information about the client's bowel motility and function. Opioid medications can decrease bowel motility and cause constipation. The nurse should assess the client's abdomen before implementing any interventions.

Choice B is not correct because providing privacy and a set time to defecate is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take.
Choice C is not correct because administering a fiber-based laxative is a pharmacological intervention that can help treat constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid intake and preference before giving a laxative.
Choice D is not correct because encouraging the client to increase oral intake of fluids is a nonpharmacological intervention that can help prevent constipation, but it is not the first action the nurse should take. The nurse should also consider the client's fluid balance and medical condition before giving fluids.

A. Ask the client's healthcare surrogate for permission to withhold nourishment. B. Request a prescription for IV fluids. C. Explain the importance of oral hydration to the client. D. Provide regular oral care for the client with a moist swab.

Correct Answer is D

Explanation

The correct answer is choice D. Provide regular oral care for the client with a moist swab. When a client with a terminal illness and in the active phase of dying refuses further hydration and nourishment, the nurse should provide comfort measures such as regular oral care to prevent discomfort. The nurse should not force the client to eat or drink or request a prescription for IV fluids. The healthcare surrogate cannot be asked for permission to withhold nourishment as the client has the right to refuse nourishment.

Option A - The client has the right to refuse nourishment, and healthcare surrogate permission is not required.

Option B - Requesting a prescription for IV fluids is not an appropriate intervention as the client has the right to refuse nourishment.

Option C - Explaining the importance of oral hydration to the client is not an appropriate intervention as the client has the right to refuse nourishment.

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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.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the plan of care for a client who has constipation after receiving opioid medication for incisional pain. Which of the following actions should the nurse take first?

Correct Answer is A

Explanation

A nurse is caring for a client who has a terminal illness and is in the active phase of dying. The client refuses further hydration and nourishment. What action should the nurse take?

Correct Answer is D

Explanation

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