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 A

Explanation

Choice A reason: Taking the client to the emergency department is crucial because missing a dialysis session can lead to severe complications such as fluid overload, high potassium levels, and other electrolyte imbalances. These conditions can be life-threatening and require immediate medical attention to stabilize the client.

Choice B reason: Applying home oxygen is not the most critical intervention in this scenario. While oxygen therapy might be necessary in some cases, it does not address the immediate risk of complications arising from missed dialysis.

Choice C reason: Ensuring that the client avoids salt intake for the rest of the day is important for managing fluid balance, but it is not the most urgent action needed in this situation. The client's lethargy and difficulty arousing indicate a more serious underlying issue that requires immediate medical evaluation.

Choice D reason: Checking for a thrill and bruit at the client's dialysis access site is important for assessing the patency of the access site, but it is not the most critical action in this scenario. The immediate concern is the client's lethargy and potential complications from missed dialysis, which necessitate emergency medical care.

A. Massage therapy. B. Structured exercise. C. Carnivore diet. D. Leg elevation.

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.

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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

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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