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:
Bradycardia is not a typical symptom of diabetes insipidus.
Choice B rationale:
Dehydration is a common symptom of diabetes insipidus due to excessive urination.
Choice C rationale:
Hyperglycemia is not a symptom of diabetes insipidus, but rather diabetes mellitus.
Choice D rationale:
Polyphagia (excessive hunger) is not a symptom of diabetes insipidus.
Correct Answer is C
Explanation
Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.
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