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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?

A.

Administer pain medication.

B.

Administer a tetanus booster.

C.

Clean and dress the wound.

D.

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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Related Questions

Correct Answer is C,A,D,E,B

Explanation

Here’s the correct order of actions a nurse should take when infiltration is identified at an IV site: C. Stop the infusion A. Remove the IV catheter D. Apply a sterile dressing E. Elevate the extremity B. Apply warm or cold compresses ? Rationale: Stopping the infusion prevents further infiltration. Removing the catheter eliminates the source of fluid leakage. Applying a sterile dressing protects the site from infection. Elevation helps reduce swelling. Compresses (warm for older infiltrations, cold for recent ones) promote absorption and comfort.

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.

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