Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Prepare IV morphine for administration by the RN.
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.
B. Apply ice to the burned area.
Applying ice to a burn can cause vasoconstriction and may increase tissue damage. It is not the first action to stop the burning process.
C. Apply a neutralizing agent.
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.
D. Remove the patient’s clothing.
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.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Lpn Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
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.
Similar Questions
Which of the following clients should be seen first?
A. A patient hospitalized with acute pancreatitis and is sitting in a high Fowler’s position leaning over the bedside table.
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
B. A patient who had bariatric surgery and is reporting shoulder pain and heart racing.
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
C. A patient who is one day post-op after an intestinal resection and colostomy, and has no effluent in the bag.
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
D. A patient with cirrhosis and is reporting loose stools.
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.
Full Explanation
Choice A rationale
A patient with acute pancreatitis sitting in a high Fowler’s position leaning over the bedside table may be experiencing discomfort, but it is not an immediate life-threatening situation.
Choice B rationale
A patient who had bariatric surgery and is reporting shoulder pain and heart racing could be experiencing complications such as a pulmonary embolism, which is a life-threatening condition. This patient should be seen first.
Choice C rationale
A patient who is one-day post-op after an intestinal resection and colostomy and has no effluent in the bag may need further assessment, but it is not an immediate life-threatening situation.
Choice D rationale
A patient with cirrhosis reporting loose stools may be uncomfortable, but it is not an immediate life-threatening situation.
The nursing assistant is delivering patient meals.
What meal should the nurse expect to be delivered to a patient who had gastric bypass surgery the day before?
A. Regular
A regular diet would be too heavy for a patient who had gastric bypass surgery the day before.
B. Clear Liquid
A clear liquid diet is typically recommended for patients who had gastric bypass surgery the day before. This diet includes broths and unsweetened juices.
C. Full liquid
A full liquid diet may be introduced after a few days post-surgery, not the day after.
D. Mechanical soft
A mechanical soft diet is typically introduced weeks after surgery, not the day after.
Full Explanation
Choice A rationale
A regular diet would be too heavy for a patient who had gastric bypass surgery the day before.
Choice B rationale
A clear liquid diet is typically recommended for patients who had gastric bypass surgery the day before. This diet includes broths and unsweetened juices.
Choice C rationale
A full liquid diet may be introduced after a few days post-surgery, not the day after.
Choice D rationale
A mechanical soft diet is typically introduced weeks after surgery, not the day after.
Which of the following nursing interventions should the nurse utilize when administering Dilantin (phenytoin) in a patient who has a known seizure disorder?
A. Hold tube feeding 1 hour before and 2 hours after to avoid clumping.
Holding tube feeding 1 hour before and 2 hours after to avoid clumping is not a specific nursing intervention when administering Dilantin (phenytoin)1011.
B. Monitor the patient for lethargy and drowsiness as these may indicate a high drug level.
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.
C. Inform the patient that they may experience increased and large amounts of urinary output.
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.
D. Advise the patient to use an extra soft toothbrush to avoid gum bleeding.
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.
Full 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.