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:
Ambulating soon after surgery is actually encouraged as it promotes blood flow and reduces the risk of VTE.
Choice B rationale:
Massaging the legs can dislodge a clot if one has formed, leading to a VTE.
Choice C rationale:
Flexing the ankles promotes blood flow and reduces the risk of VTE.
Choice D rationale:
Elevating the feet can reduce swelling and promote venous return, reducing the risk of VTE.
Correct Answer is A
Explanation
Choice A rationale:
Basal cell carcinoma often appears as a raised, flesh-colored lesion with pearly, white borders. It is the most common type of skin cancer.
Choice B rationale:
Actinic keratosis is a precancerous skin condition that can lead to squamous cell carcinoma if left untreated. It typically presents as dry, scaly patches or spots.
Choice C rationale:
Squamous cell carcinoma often appears as a firm, red nodule or a flat lesion with a scaly, crusted surface.
Choice D rationale:
Malignant melanoma is a more serious type of skin cancer that can develop anywhere on the body. It often appears as a new, irregular, or changing mole.
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