A patient with chemical burns to the chest and abdomen is admitted to the emergency department.
The registered nurse begins to flush the area with sterile saline.
What is the first action the LPN should take to stop the burning process?
Prepare IV morphine for administration by the RN.
Apply ice to the burned area.
Apply a neutralizing agent.
Remove the patient’s clothing.
The Correct Answer is D
Choice A rationale
While pain management is important in burn care, the first action should be to stop the burning process. Administering IV morphine does not achieve this.
Choice B rationale
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
Choice C rationale
Applying a neutralizing agent is not the first action in chemical burn management. The priority is to remove the chemical from contact with the skin.
Choice D rationale
Removing the patient’s clothing is the first action in burn management. This prevents further contact of the chemical with the skin and stops the burning process.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is []
Explanation
Based on the provided exhibits, the client is most likely experiencingBacterial Meningitis. This is indicated by symptoms such as severe headache, fever, sensitivity to light, nuchal rigidity, and the presence of Neisseria meningitidis in the cerebrospinal fluid with elevated white blood cell count and lactic acid levels.
The two actions the nurse should take to address this condition are:
- Anticipate administering antibiotic therapy- This is crucial as the client’s culture and sensitivity test indicates the presence of Neisseria meningitidis, which requires antibiotic treatment.
- Place the client on droplet precautions- Since Neisseria meningitidis can be spread through respiratory droplets, it is important to implement droplet precautions to prevent the spread of infection.
The two parameters the nurse should monitor to assess the client’s progress are:
- Level of consciousness- Monitoring for changes in the client’s level of consciousness can indicate the effectiveness of the treatment and the progression of the disease.
- Increased intracranial pressure- Signs of increased intracranial pressure can include changes in vital signs, level of consciousness, and the presence of headache or vomiting. Monitoring these signs is important in the management of bacterial meningitis.
Correct Answer is B
Explanation
Choice A rationale
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice B rationale
Monitoring the patient for lethargy and drowsiness is important as these may indicate a high drug level of Dilantin (phenytoin), which can lead to toxicity.
Choice C rationale
Informing the patient that they may experience increased and large amounts of urinary output is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
Choice D rationale
Advising the patient to use an extra soft toothbrush to avoid gum bleeding is a general recommendation for patients on anticoagulant therapy, not specifically for those taking Dilantin (phenytoin)1011.
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