The nurse is assisting with the care of a patient admitted to the emergency department with chemical burns across the chest and hands. Which of the following actions should be included in the plan of care? (Select all that apply.)
a. Obtain a history of the event and burning agent.
b. Cover the patient with a clean sheet.
c. Apply ice packs to burn sites.
d. Provide copious tepid water lavage for 20 minutes.
e. Remove all contaminated clothing.
f. Apply neutralizing agent to burn area.
ANS: A, B, D, E
Initiate immediate copious tepid water lavage for 20 minutes for all chemical burns, along with simultaneous removal of contaminated clothing. (Do not neutralize chemical because this takes too much time, and the resulting reaction may generate heat and cause further skin injury.) Obtain a history of the burning agent. Do not apply ice.
You might also like to view...
A client who has diabetes begins to experience nausea, vomiting, weakness, fatigue, and blurred vision. The nurse observes the client's skin is warm and flushed and notes a fruity odor to the client's breath
The nurse should anticipate the client will be treated for: a. hypoglycemia b. diabetic ketoacidosis c. hyperosmolar hyperglycemic nonketotic syndrome d. insulin resistance
The nurse suspects fluid overload in an infant receiving intravenous fluids. What clinical manifestation is suggestive of water intoxication?
a. Oliguria b. Weight loss c. Irritability and seizures d. Muscle weakness and cardiac dysrhythmias
The nurse would select Imbalanced nutrition: less than body requirements as a nursing diagnosis if the client had which of the following defining characteristics?
1. fewer dollars to spend on groceries than previously spent 2. no help from family members in food preparation 3. anorexia and loss of interest in food 4. lack of information about nutrient content of specific foods
Which descriptor is vital to effective team function?
a. Desired c. Accepted b. Known d. Clear