The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

chemical burns to the posterior neck, chest, and back

radiation burns to shoulder and bridge of nose

electrical burns to the hands causing dysrhythmias

thermal burns to the head, neck, face, and airway.

Answer and Explanation

The Correct Answer is D

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

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Correct Answer is A

Explanation

A) Be placed in isolation to prevent radiation exposure to others:
Radioactive iodine (I-131) is commonly used to treat thyroid cancer because it targets and destroys thyroid tissue, including any remaining cancerous cells. This treatment involves the administration of a radioactive substance that can be excreted through saliva, urine, and sweat. To minimize radiation exposure to others, patients are often placed in isolation, particularly in a hospital setting, for a period following administration.

B) Avoid consuming any food or fluids for 24 hours prior to the treatment:
While it’s essential for patients to follow specific instructions regarding food and fluid intake, such as avoiding certain foods or fluids that may interfere with absorption or increase the risk of side effects (like dairy products), the patient does not need to avoid all food and fluids for 24 hours after receiving radioactive iodine.

C) Avoid all physical activity for six weeks after the treatment:
While some precautions, such as avoiding close contact with others for a short period of time, may be necessary, avoiding physical activity for six weeks is not usually required. Patients may be advised to take it easy during the initial recovery phase, but they can typically resume normal activities once the initial isolation period is complete and their radiation exposure is below safety thresholds.

D) Discontinue all other medications for a week before treatment:
However, certain medications that affect thyroid function (such as thyroid hormones or antithyroid medications) may need to be adjusted or stopped before treatment to ensure the effectiveness of the radioactive iodine. The specifics would depend on the patient’s condition and the healthcare provider’s instructions.

A. Establish IV access apply 2L O2 via nasal cannula, and notify provider B. Assess below injury for noxious stimuli anticipate order hypertensive medication C. Administer acetaminophen and initiate intravenous (IV) fluids anticipate order for atropine D. Lower the head of the bed and apply a cool compress to the forehead

Correct Answer is B

Explanation

A) Establish IV access, apply 2L O2 via nasal cannula, and notify provider:
While establishing IV access and providing oxygen are important aspects of managing many emergencies, this patient's symptoms suggest the presence of autonomic dysreflexia rather than a primary respiratory or circulatory issue. In autonomic dysreflexia, the primary concern is to remove the noxious stimulus (such as a full bladder, bowel impaction, or tight clothing) that is causing the severe hypertension and bradycardia.

B) Assess below injury for noxious stimuli, anticipate order for hypertensive medication:
The patient’s symptoms are consistent with autonomic dysreflexia, a serious condition that occurs in individuals with a spinal cord injury at or above the T6 level. The body’s autonomic nervous system overreacts to noxious stimuli (such as a distended bladder, bowel impaction, or skin irritation) below the level of injury, leading to a severe hypertensive crisis, bradycardia, and sympathetic hyperactivity. The nurse should immediately assess for and relieve any noxious stimuli below the injury level (e.g., checking for a full bladder, constipation, or tight clothing) and anticipate an order for antihypertensive medications if the blood pressure remains elevated.

C) Administer acetaminophen and initiate intravenous (IV) fluids, anticipate order for atropine:
While pain and discomfort (which can exacerbate autonomic dysreflexia) may need to be managed, acetaminophen is not the priority in this case. The priority is addressing the underlying cause of autonomic dysreflexia, such as relieving noxious stimuli. Additionally, atropine is used for bradycardia, but in autonomic dysreflexia, the bradycardia is secondary to the hypertensive crisis and usually resolves once the noxious stimulus is removed.

D) Lower the head of the bed and apply a cool compress to the forehead:
Although lowering the head of the bed may help reduce intracranial pressure and applying a cool compress may provide comfort, these interventions do not address the underlying cause of the autonomic dysreflexia.

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The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

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Naxlex Comprehensive Predictor Exams

The nurse should implement which safety consideration for a patient when administering oral radioactive iodine for thyroid cancer? The patient should:

Correct Answer is A

Explanation

The nurse assesses the patient with a spinal cord injury at the level C-7 and finds warm, flushed skin with profuse sweating above the level of injury, and pale, cold skin below the level of injury. The patient is bradycardic, but severely hypertensive. What are the priority nursing interventions?

Correct Answer is B

Explanation

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