A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
Increase the room temperature.
Cleanse the client's wounds.
Administer analgesic medication.
Start an IV with a large-bore needle.
The Correct Answer is D
D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Albumin is a protein that plays a crucial role in maintaining skin health. Low albumin levels (hypoalbuminemia) can lead to poor wound healing and skin vulnerability.
Hemoglobin level, white cell count and 25-hydroxyvitamin have no direct role in skin breakdown.
Correct Answer is ["B","C","E"]
Explanation
B. Monitoring serum blood glucose during infusion is important because TPN can contain glucose, which may affect the client's blood glucose levels. Regular monitoring helps ensure glycemic control and prevents complications such as hyperglycemia.
C. Double-checking the TPN solution with another RN is a crucial safety measure to prevent medication errors and ensure that the correct solution is administered to the client.
E. Monitoring the client's weight daily is important for assessing fluid balance and adjusting the TPN infusion rate accordingly. Changes in weight can indicate fluid retention or loss, which may require adjustments to the TPN prescription.
A. TPN solutions must be administered according to the prescribed rate and schedule. Increasing the infusion rate without medical orders could lead to complications such as hyperglycemia or fluid overload.
D. TPN solutions are specifically formulated to meet the client's nutritional needs and cannot be substituted with other intravenous solutions like 0.9% sodium chloride.
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