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 A

Explanation

Choice A rationale:
Dextrose 10% in water can be used as a temporary replacement for TPN to prevent hypoglycemia until the TPN solution is available.
Choice B rationale:
3% sodium chloride is a hypertonic solution and is not typically used as a replacement for TPN.
Choice C rationale:
0.9% sodium chloride, or normal saline, does not provide the necessary nutrients that are included in TPN.
Choice D rationale:
Lactated Ringer’s is used for fluid resuscitation and does not provide the necessary nutrients that are included in TPN.

A. Increased heart rate. B. Increased respiratory rate. C. Increased temperature. D. Increased hematocrit. E. Increased blood pressure.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale:
Increased heart rate is a compensatory mechanism to maintain cardiac output in the presence of fluid overload.
Choice B rationale:
Increased respiratory rate may occur due to pulmonary congestion caused by fluid overload.
Choice C rationale:
Increased temperature is not typically associated with fluid overload.
Choice D rationale:
Increased hematocrit would indicate dehydration, not fluid overload.
Choice E rationale:
Increased blood pressure can occur due to increased blood volume in fluid overload.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.).

Correct Answer is ["A","B","E"]

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?