A client with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?
Assess oral temperature.
Place on cardiac monitor.
Check a potassium level.
Assess for pain at contact points.
The Correct Answer is B
A. Assessing oral temperature is not a priority immediately after an electrical burn, as the focus should be on monitoring for cardiac issues and other life-threatening conditions.
B. Electrical burns can cause cardiac arrhythmias, including dysrhythmias like ventricular fibrillation, which can be life-threatening. The nurse should place the client on a cardiac monitor immediately to detect any abnormal rhythms and respond accordingly.
C. While checking potassium levels is important for assessing potential complications such as kidney damage or arrhythmias, cardiac monitoring should take precedence.
D. Assessing for pain at contact points is important, but it is secondary to ensuring cardiac stability in an electrical burn victim.
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Related Questions
Correct Answer is B
Explanation
A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.
B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.
C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.
D. Having the water turned on does not pose a significant risk for infection or sepsis.
Correct Answer is B
Explanation
A. A small, mobile, rubbery lump is often benign, such as a fibroadenoma.
B. A nontender, fixed breast nodule is concerning for malignancy, and further evaluation is necessary, such as imaging or biopsy.
C. Tender, bilateral nodules are commonly seen in benign conditions like fibrocystic breast changes, especially related to the menstrual cycle.
D. A lump that changes in size before menstruation is also typical of benign conditions like fibrocystic changes.
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