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Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

Wearing sunglasses while symptomatic

Applying an eye patch before sleep

An antihistamine eye drop

Antibiotic ophthalmic ointment

Answer and Explanation

The Correct Answer is B

A. Wearing sunglasses while symptomatic

Sunglasses reduce photophobia, but they do not prevent corneal damage from dryness.

B. Applying an eye patch before sleep

Bell's palsy affects cranial nerve VII (facial nerve), leading to incomplete eye closure. This can cause corneal abrasions and dryness. An eye patch at night prevents corneal injury.

C. An antihistamine eye drop

Antihistamine eye drops may dry out the eye further, worsening the risk of corneal injury.

D. Antibiotic ophthalmic ointment

Antibiotics are not necessary unless an infection is present. Lubricating drops or artificial tears are more appropriate.

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Correct Answer is A

Explanation

A. Fluid resuscitation

Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.

B. Transfer to a burn center

While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.

C. Application of sterile dressings

Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.

D. Administer morphine 8 mg IV

Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.

A. Auscultate bowel sounds, record the findings and obtain a 12-lead ECG B. Initiate the standing prescription for v Dopamine at 16 mcg/kg/minute C. Place soft restraints on the upper extremities and sedate as necessary D. Lower the head the bed obtain a pulse ox and increase the rate of iv fluids

Correct Answer is D

Explanation

A. Auscultate bowel sounds, record the findings, and obtain a 12-lead ECG
While auscultating bowel sounds can help assess for bowel injury and an ECG is useful for monitoring cardiac function, these interventions are not the priority. The client is in shock and requires immediate intervention to restore perfusion.

B. Initiate the standing prescription for Dopamine at 16 mcg/kg/minute
Dopamine can be used to support blood pressure in shock, but fluid resuscitation is the first-line intervention in hypovolemic shock. Vasopressors like dopamine are typically added after fluid resuscitation if hypotension persists.

C. Place soft restraints on the upper extremities and sedate as necessary
The client's restlessness is likely due to hypoxia and inadequate perfusion, not agitation. Restraints and sedation would delay critical interventions and could worsen hemodynamic instability.

D. Lower the head of the bed, obtain a pulse ox, and increase the rate of IV fluids
The client is in hypovolemic shock due to suspected internal bleeding. Lowering the head of the bed improves cerebral perfusion, increasing IV fluids restores intravascular volume, and checking pulse oximetry ensures adequate oxygenation. This is the priority action to stabilize the client.

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Due to cranial nerve involvement in Bell's palsy, which of the following would prevent a potential complication from the disorder?

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

A client with hypovolemic shock who did not respond to fluid resuscitation is started on norepinephrine. What is the desired outcome?

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The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (Select All that Apply)

Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

The nurse is caring for a client with 40% full thickness burned total body surface area (TBSA) in the Emergency Department. The nurse is awaiting transfer to a regional burn center within 20 minutes. What is the most appropriate initial wound care management while awaiting transfer?

The nurse is caring for an adult with a burn injury. The following parts of the patient's body were burned: anterior and posterior right arm, posterior trunk. and posterior right leg. Using the Rule of Nines, calculate the Total Body Surface Area (TBSA) percentage that is involved.