The nurse is caring for a client who presents with a chemical burn to the right hand, what should the nurse do first?
Elevate the extremity and apply an ice pack to the injured area
Contact poison control to determine the best neutralizing agent
Apply a sterile dressing, wrapping the fingers separately
Irrigate the affected area with room temperature water
The Correct Answer is D
A. Elevate the extremity and apply an ice pack to the injured area
Elevating the extremity can help reduce swelling, but applying ice is not recommended for chemical burns as it can cause further tissue damage.
B. Contact poison control to determine the best neutralizing agent
While contacting poison control is important, it should not be the immediate first action in an emergency setting.
C. Apply a sterile dressing, wrapping the fingers separately
This is important for protecting the wound, but it is not the immediate first action needed for chemical burns.
D. Irrigate the affected area with room temperature water
Immediate irrigation with room temperature water helps to remove the chemical from the skin and dilute its effect, which is the first critical step in managing a chemical burn.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Assessment of neurologic status
While neurological assessment is important, it is not the priority in this situation. The immediate priority is managing the chest wound and airway to ensure oxygenation and prevent further complications.
B. Obtain IV access with two large bore lines and blood for lab studies
IV access is important for fluid resuscitation and medication administration but is not the immediate priority compared to securing the airway and ensuring ventilation.
C. Placement of a naso-gastric tube to decompress the stomach
Although the naso-gastric tube may be necessary to decompress the stomach later, it is not the priority in the initial management of a client with a gunshot wound to the chest.
D. Placement of an indwelling catheter (Foley) to measure urine output
While measuring urine output is important for monitoring renal function and fluid balance, it is not the priority in this emergency situation.
Correct Answer is B
Explanation
A. Mini mental status exam at admission and discharge
Useful for cognitive function but not for acute changes.
B. Performing serial Glasgow Coma Scale exams
The GCS is the best tool for tracking changes in neurologic status over time.
C. Assessing pupils for reactivity, equality, symmetry, and accommodation
Important but not comprehensive.
D. Obtaining vital signs every four hours
Useful but does not specifically assess neurologic function.
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