The practical nurse (PN) is caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg. Which priority action should the PN take while caring for this patient?

Anticipate rehydration of 1000 mL/6 hr. with normal saline.

Remove clothing, cover burned area with cool damp cloth.

Completely ﬂush burned area with water or sterile saline.

Collect data, vital signs, blood gases, height and weight.

Answer and Explanation

The Correct Answer is B

The priority action for the practical nurse (PN) to take while caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg is to remove clothing and cover the burned area with a cool damp cloth. This will help to cool the burn and reduce pain.

Anticipating rehydration of 1000 mL/6 hr. with normal saline (Option A) is an important intervention for burn patients, but it is not the first priority. Completely ﬂushing the burned area with water or sterile saline (Option C) may be appropriate in some cases, but it is not the first intervention that should be implemented. Collecting data such as vital signs, blood gases, height and weight (Option D) is also important, but it is not the first priority.

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Correct Answer is C

Explanation

A positive indirect Coombs' test indicates that the mother has developed Rh antibodies against the baby's Rh-positive blood. This finding can result in hemolytic disease of the newborn, which is a condition in which the mother's Rh antibodies atack the baby's red blood cells, causing destruction and potential anemia.

The baby may require phototherapy for physiologic jaundice, but the Coombs' test result indicates a diﬀerent issue.

The presence of an infectious blood-borne disease cannot be determined from this test.

The mother may still need Rho (D) immune globulin injections after delivery of an Rh-positive baby.

A. Contact information for a women's shelter. B. Safety plan to keep in a purse at all times. C. Visit summary documenting the report of abuse. D. Paperwork needed to file a restraining order.

Correct Answer is A

Explanation

This can oﬀer a safe place for her and her unborn child. The shelter can also provide resources for counseling and legal assistance if needed.

The safety plan and restraining order are important measures, but the priority should be to ensure the client's immediate safety.

The visit summary documenting the report of abuse is also important, but it should not be the only information provided to the client.

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The practical nurse (PN) is caring for a client that has just arrived in the emergency department with 2nd degree thermal burns to the right thigh, lower leg and foot, and reports severe pain in the right leg. Which priority action should the PN take while caring for this patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with blood type AB negative delivers a newborn with blood type A positive. The cord blood reveals a positive indirect Coombs' test. What is the implication of this finding?

Correct Answer is C

Explanation

At a prenatal visit, a primigravida client confides to the practical nurse (PN) that her partner is abusive. Which information should the PN provide?

Correct Answer is A

Explanation

The practical nurse (PN) is caring for a client in the preoperative holding area who is waiting for abdominal surgery. The client tells the PN about feeling afraid and anxious because of the surgery. Which technique is best for the PN to assist the client to use while waiting for surgery?

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