Nokea
The emergency room nurse is caring for a patient with severe burns knows that the priority immediate intervention is which of the following?
- A. Cover the burns to prevent infection
- B. Provide anti-inflammatory medication
- C. Stop the burning process
- D. Provide anti-cyanide medication
Correct Answer: C
Rationale: The correct answer is C: Stop the burning process. This is the priority immediate intervention for a patient with severe burns because stopping the burning process helps prevent further tissue damage. It involves removing the patient from the source of the burn, extinguishing any flames, and cooling the burn with water. This action is crucial in minimizing the extent of the injury and improving outcomes.
A: Covering the burns to prevent infection is important but not the immediate priority.
B: Providing anti-inflammatory medication can be considered later but is not the primary immediate intervention.
D: Providing anti-cyanide medication is not relevant for severe burns.
You may also like to solve these questions
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. In bacterial pneumonia, the body's immune response leads to systemic symptoms like malaise, fatigue, and weakness. This is due to the infection fighting process. Drooling (A) is not a common manifestation of bacterial pneumonia. Tinnitus (C) refers to ringing in the ears and is not associated with pneumonia. Rhinorrhea (D) is more commonly seen in viral respiratory infections.
A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. This is the priority finding because morphine, an opioid, can cause respiratory depression leading to bradypnea or slow breathing. Monitoring the child's respiratory status is crucial to prevent respiratory compromise or arrest. A: Constipation is a common side effect but not an immediate concern. B: Sedation is expected after receiving morphine but not as critical as respiratory depression. D: Euphoria is a possible side effect but not as concerning as respiratory depression. Thus, the priority is to monitor for signs of respiratory depression to ensure the child's safety.
Which are appropriate actions to manage a hospitalized child with hemophilia? (Select all that apply).
- A. Administer Factor VII for bleeding crises
- B. Administer platelets for bleeding crises
- C. Avoid unnecessary skin punctures
- D. Administer Ibuprofen for complaints of discomfort
Correct Answer: A,C
Rationale: The correct answers are A and C. Administering Factor VII helps in managing bleeding crises in hemophiliac patients. Factor VII aids in clotting, essential for stopping bleeding. Avoiding unnecessary skin punctures reduces the risk of bleeding episodes in hemophilia patients. Platelets (B) and Ibuprofen (D) are not appropriate for managing hemophilia. Platelets do not address the underlying clotting factor deficiency in hemophilia, and Ibuprofen can worsen bleeding due to its antiplatelet effects.
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
- B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
- C. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Applying continuous pressure 2.5 cm below the percutaneous skin site will help control bleeding by promoting clot formation at the catheter insertion site. This pressure point is closer to the source of bleeding, ensuring better hemostasis and preventing further complications.
Summary:
A: Applying intermittent pressure below the site is incorrect as continuous pressure is more effective in achieving hemostasis.
B: Applying continuous pressure above the site is incorrect as it does not target the bleeding source directly.
D: Applying intermittent pressure above the site is incorrect as continuous pressure is preferred for controlling bleeding.
E, F, G: No information provided.
A child being administered a new medication displays signs of an adverse drug reaction. The nurse would expect treatment of the reaction to include (Select all that apply):
- A. Administering antibiotics
- B. Discontinuing the drug
- C. Administering antihistamines
- D. Administering corticosteroids
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Discontinuing the drug is essential to stop the adverse reaction. Administering antihistamines helps manage symptoms like itching and hives. Corticosteroids can reduce inflammation and allergic responses caused by the reaction. Antibiotics (choice A) are not indicated unless there is a specific infection requiring treatment. No other choices were provided, but it's crucial to focus on stopping the offending drug, managing symptoms, and addressing inflammation in the case of an adverse drug reaction.