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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Correct Answer is C

Explanation

Choice A rationale:
Trimming the nails at the lateral corners can lead to ingrown toenails, which can cause pain and infection.
Choice B rationale:
Cleaning under the nail with an orange stick can cause injury to the nail bed and lead to infection.
Choice C rationale:
Filing the nails in a rounded shape can prevent injury and is the recommended method for nail care.
Choice D rationale:
Pushing the cuticles back with a metal nail file can cause injury and infection.

A. Obtain impedance plethysmography. B. Apply cold therapy to the affected leg. C. Obtain a venous duplex ultrasound. D. Monitor Homan's sign.

Correct Answer is C

Explanation

Choice A rationale:
Impedance plethysmography is a test that uses electrical signals to measure blood flow and can be used to detect deep vein thrombosis (DVT). However, it is not the first-line diagnostic tool for DVT.
Choice B rationale:
Cold therapy can help reduce inflammation and pain, but it is not a diagnostic measure for DVT.
Choice C rationale:
Venous duplex ultrasound is the most common test used to diagnose DVT. It uses sound waves to create pictures of the blood flowing through the veins in the leg.
Choice D rationale:
Homan’s sign is a physical examination finding that was traditionally used to diagnose DVT, but it is not reliable or specific.

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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

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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?