A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

Remove clothing and jewelry but avoid peeling off adhered skin

Establish IV access and initiate fluid resuscitation

Prepare for wound care and Wound debridement

Assess for smoke inhalation injury and airway swelling

Answer and Explanation

The Correct Answer is D

A. Remove clothing and jewelry but avoid peeling off adhered skin. While removing clothing and jewelry is necessary to prevent further tissue damage and swelling, it is not the highest priority in the initial assessment. Airway assessment must come first.

B. Establish IV access and initiate fluid resuscitation. Fluid resuscitation is crucial to prevent hypovolemic shock, but airway assessment and management take priority, especially in burns affecting the face, neck, and upper chest.

C. Prepare for wound care and wound debridement. Wound care is important but is not the first priority in emergency management. The airway must be secured first before addressing other concerns.

D. Assess for smoke inhalation injury and airway swelling. The greatest risk in burn patients, especially those with burns to the face, neck, or chest, is airway compromise due to inhalation injury or swelling. Airway assessment and securing the airway take priority before fluid resuscitation or wound care.

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Correct Answer is B

Explanation

A. Apply an antibiotic ointment and reassess in two weeks. SCC is a form of skin cancer and requires biopsy for diagnosis. Simply applying an antibiotic and waiting could delay necessary treatment.

B. Refer the patient to a dermatologist for a biopsy. The priority action for a suspicious lesion that does not heal is to refer the patient for biopsy and further evaluation, as early detection and treatment of SCC are crucial.

C. Reassure the patient that the lesion is benign and monitor for changes. SCC can be aggressive if untreated, and assuming benignity without biopsy could result in delayed diagnosis and worsening prognosis.

D. Educate the patient on proper wound care and sun protection. While wound care and sun protection are important, the priority is obtaining a definitive diagnosis through biopsy.

A. “I should turn my toes inward when lying down.” B. “I can bend my hip more than 90 degrees when sitting in a chair.” C. “I should cross my legs when sitting to improve circulation." D. “I should use an abduction pillow between my legs while in bed."

Correct Answer is D

Explanation

A. “I should turn my toes inward when lying down.” Internal rotation of the hip increases the risk of dislocation and should be avoided.

B. “I can bend my hip more than 90 degrees when sitting in a chair.” Flexing the hip beyond 90 degrees increases dislocation risk and should be avoided.

C. “I should cross my legs when sitting to improve circulation." Crossing the legs can lead to hip adduction and dislocation. Instead, legs should remain apart.

D. “I should use an abduction pillow between my legs while in bed.” An abduction pillow keeps the legs in proper alignment and prevents dislocation by maintaining slight abduction.

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A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

Which of the following statements by the patient indicates correct understanding of postoperative hip precautions?

Correct Answer is D

Explanation

The nurse is evaluating a patient's understanding of cast care before discharge. Which statement by the patient indicates the need for further teaching?

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