A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Continuous cardiac monitoring

Evaluate level of consciousness

Perform passive range of motion

Assess lung sounds every 4 hours

Answer and Explanation

The Correct Answer is A

Choice A reason: Continuous cardiac monitoring is crucial for a client who has suffered an electrical injury. Electrical injuries can cause arrhythmias and other cardiac complications, which may not be immediately apparent. Continuous monitoring allows for the early detection and treatment of any cardiac abnormalities, which is vital for the patient's safety and recovery.

Choice B reason: Evaluating the level of consciousness is important for any patient, especially those with significant injuries, but it is not the most critical intervention in this scenario. While neurological assessments are part of comprehensive care, the immediate risk posed by cardiac complications from the electrical injury takes precedence.

Choice C reason: Performing passive range of motion exercises is beneficial for preventing contractures and maintaining joint mobility in immobile patients. However, it is not the most urgent intervention in the context of an electrical injury, where cardiac monitoring is paramount.

Choice D reason: Assessing lung sounds every 4 hours is a valuable part of monitoring for respiratory complications, particularly in burn patients. However, the immediate cardiac risks associated with electrical injuries necessitate continuous cardiac monitoring as the priority intervention.

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Correct Answer is B

Explanation

Choice A reason: Massage therapy can help with relaxation and improving circulation in some cases, but it is not a primary intervention for managing PAD. Structured exercise is more effective in improving symptoms and overall cardiovascular health.

Choice B reason: Structured exercise is the most appropriate intervention for a client with PAD. Regular physical activity, especially walking, can help improve blood flow, reduce symptoms, and enhance overall cardiovascular health. It is recommended that clients with PAD engage in a supervised exercise program to ensure safety and effectiveness.

Choice C reason: A carnivore diet is not recommended for clients with PAD. A heart-healthy diet that includes a variety of fruits, vegetables, whole grains, lean proteins, and healthy fats is more beneficial for managing PAD and reducing cardiovascular risk factors.

Choice D reason: Leg elevation can help reduce swelling and improve comfort, but it is not a primary intervention for managing PAD. Structured exercise has a more significant impact on improving blood flow and reducing symptoms.

A. Infection prevention related to appendicitis B. Relief of acute pain C. Client education about diagnosis and plan of care D. Effective coping with illness-related anxiety E. Prevention of deep vein thrombosis related to immobility F. Promotion of bowel routine G. Fluid volume management

Correct Answer is ["A","B","C","D","G"]

Explanation

Choice A reason:

Infection prevention is crucial in managing appendicitis. Administering preoperative antibiotics, such as cefazolin, helps prevent surgical site infections and other complications. This aligns with standard care protocols for appendicitis patients.

Choice B reason:

Relieving acute pain is a priority in appendicitis care. Administering analgesics, including opioids, acetaminophen, and NSAIDs, effectively manages pain and reduces inflammation. Providing distraction techniques can also help alleviate discomfort until pain relief is achieved.

Choice C reason:

Client education about the diagnosis and plan of care is essential. Informing the patient about appendicitis, the surgical procedure, and postoperative expectations reduces anxiety and promotes cooperation. Effective communication enhances patient outcomes and satisfaction.

Choice D reason:

Effective coping with illness-related anxiety is important. Providing emotional support and addressing concerns can help the patient manage anxiety associated with the diagnosis and impending surgery. This approach contributes to overall well-being and recovery.

Choice G reason:

Fluid volume management is vital in appendicitis care. Administering intravenous fluids, such as Ringer's lactate, maintains hydration, supports renal function, and prepares the patient for surgery. Proper fluid balance is essential for optimal physiological function.

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A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client’s plan of care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing home care instructions for a client with peripheral artery disease (PAD). Which intervention should the nurse include?

Correct Answer is B

Explanation

Exhibits The nurse is stabilizing the client and preparing her for surgery. Which goals should the nurse prioritize in the plan of care for the client while in the emergency department (ED)? Select all that apply.

Correct Answer is ["A","B","C","D","G"]

Explanation

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