A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?
Cool and clammy skin
Purulent drainage from the burn site
Muscle weakness
Irregular heart rhythm
The Correct Answer is D
A. Cool and clammy skin:
May indicate shock but is not specific to electrical burns.
B. Purulent drainage from the burn site:
Suggests infection, a later complication rather than immediate concern.
C. Muscle weakness:
Can occur but is less urgent than cardiac effects.
D. Irregular heart rhythm:
Electrical burns can cause internal cardiac damage and arrhythmias-potentially life-threatening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Sodium level: Serum sodium levels can vary and are not a direct measure of fluid retention.
B. Tissue edema: Edema is subjective and can be influenced by other conditions.
C. Urinary output: Many CKD patients have limited or no urine output despite fluid retention.
D. Daily weight: Daily weights are the most reliable non-invasive measure for fluid status.
Correct Answer is B
Explanation
A. Evaluating the patient's level of pain after medication administration: This is important but comes after the medication is given.
B. Ensuring a bag valve mask (BVM) is at the bedside: Opioids and sedatives depress respiratory drive. Emergency resuscitation equipment (like a BVM) must be ready in case of respiratory compromise.
C. Verification of allergies to medications: Important, but verifying allergies should already be done before administering any meds; not the priority here.
D. Documenting the level of pain before medication administration: Also important, but secondary to safety preparation.
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