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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Placing the client back in bed during a seizure could potentially cause injury. The priority is to protect the client from harm during the seizure.
Choice B rationale:
Placing the client on his side, specifically the recovery position, helps keep the airway clear and prevents aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause injury. It’s important to let the seizure take its course while protecting the client from harm.
Choice D rationale:
Inserting a tongue blade or any other object in the client’s mouth during a seizure is not recommended. It could cause injury to the client or the nurse.
Correct Answer is C
Explanation
Choice A rationale:
Cleaning the perineal area with antiseptic solution daily is not necessary and can disrupt normal flora.
Choice B rationale:
Routine irrigation of the catheter is not recommended as it can introduce bacteria.
Choice C rationale:
Checking the catheter tubing for kinks or twisting ensures urine flow and prevents infection.
Choice D rationale:
Replacing the catheter every 3 days is not necessary and can increase infection risk.
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