A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

Change dressings over the entrance and exit wounds.

Obtain an ECG.

Administer an opioid pain medication.

Titrate IV fluids to maintain urine output at 75 mL/hr.

Answer and Explanation

The Correct Answer is B

A.   Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B.   Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C.   Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D.   While maintaining adequate urine output is important, assessing cardiac status takes precedence.

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Correct Answer is C

Explanation

A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

A. Obtain a board that uses colored pictures as communication. B. Request an interpreter during the initial assessment. C. Familiarize themselves with commonly used signed language. D. Ask a family member to be present during the admission.

Correct Answer is B

Explanation

A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.

D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.

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A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?

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Naxlex Comprehensive Predictor Exams

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