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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?

A.

Change dressings over the entrance and exit wounds.

B.

Obtain an ECG.

C.

Administer an opioid pain medication.

D.

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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Related Questions

Correct Answer is A

Explanation

A) Disposing of the top of the ampule in a sharps container is essential for safety to prevent accidental injuries from broken glass.
B) While placing a paper towel around the ampule's neck to break off the top with both hands is a good practice to prevent injury, it's not the primary action needed for safe disposal.
C) Expelling air into the ampule to aspirate air bubbles is unnecessary and could contaminate the medication.
D) Withdrawing the medication from the ampule using a needleless system is not typically done with ampules, as they are usually designed for single-use and require breaking the top off to access the medication.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"C"},"E":{"answers":"A"},"F":{"answers":"C"}}

Explanation

A) Coughing is not directly related to the client's condition as described in the scenario.
B) Keeping the client's head in a midline position is anticipated to maintain an open airway and prevent further complications, particularly after a cerebrovascular accident.
C) Elevating the head of the bed is anticipated as it can help improve respiratory function and reduce intracranial pressure, which is beneficial given the client's history of cerebrovascular accident and current restlessness and agitation.
D) Assisting the client to the bathroom is contraindicated due to the client's current unresponsiveness and risk of falls; a bedpan or catheter may be more appropriate.
E) Initiating seizure precautions is anticipated because the client's Glasgow Coma Scale score indicates a decreased level of consciousness, which could predispose them to seizures, especially with a history of cerebrovascular accident.
F) Decreasing oxygen to 1.5 L/min via nasal cannula is contraindicated given the client's decreased oxygen saturation levels; instead, the nurse should anticipate the need to maintain or increase oxygen to ensure adequate tissue perfusion.

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