A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.

Which of the following interventions should the nurse perform first?

Administer pain medication.

Administer a tetanus booster.

Clean and dress the wound.

Administer IV fluids.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

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Free Nursing Study Resources

Correct Answer is ["A","C","D","E"]

Explanation

Choice A rationale:
A distended bladder is a common sign of urinary retention, which can occur with prostatic hypertrophy. The enlarged prostate can block the flow of urine, causing the bladder to become distended.
Choice B rationale:
Dysuria, or painful urination, is not typically associated with urinary retention. It is more commonly seen in urinary tract infections.
Choice C rationale:
Feeling pressure is a common symptom of urinary retention. The pressure is caused by the buildup of urine in the bladder.
Choice D rationale:
Voiding small amounts frequently can be a sign of urinary retention. The bladder is not able to fully empty, so small amounts of urine are passed frequently.
Choice E rationale:
Tenderness over the symphysis pubis can be a sign of a distended bladder. The bladder is located just behind the symphysis pubis, so distention can cause tenderness in this area.

A. Impaired tissue perfusion. B. Alteration in activity tolerance. C. Impaired skin integrity. D. Alteration in body image.

Correct Answer is A

Explanation

Choice A rationale:
Varicose veins with ulcerations and lower extremity edema indicate poor blood flow, hence impaired tissue perfusion is the priority.
Choice B rationale:
While activity tolerance might be affected, it’s not the immediate concern.
Choice C rationale:
Impaired skin integrity is a concern due to ulcerations, but it’s secondary to impaired perfusion.
Choice D rationale:
Body image might be affected, but it’s not a physiological priority.

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A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing prostatic hypertrophy. Which of the following findings associated with urinary retention should the nurse expect? (Select all that apply.).

Correct Answer is ["A","C","D","E"]

Explanation

Correct Answer is A

Explanation

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A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.

Which of the following interventions should the nurse perform first?