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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The fact that the patient is being treated for depression and is currently taking an antidepressant medication suggests that his loss of interest in sexual intimacy may be related to his medication. Certain antidepressants can cause sexual dysfunction, including decreased libido.
Therefore, obtaining a list of medications currently being taken (A) is the most important information for the PN to obtain. While marital discord (B), frequency of sexual activity (C), and alcohol consumption (D) may be relevant information, they are not as directly related to the patient's current complaint as his medication use.
Correct Answer is D
Explanation
Gestational diabetes mellitus (GDM) is a type of diabetes that occurs during pregnancy. If euglycemia, or normal blood glucose levels, is not maintained during pregnancy, the fetus can be at risk for a number of complications. The greatest risk to the fetus in this situation is the development of a macrosomic newborn, or a newborn that is significantly larger than average. This occurs because the excess glucose in the mother's bloodstream is passed on to the fetus, leading to excessive fetal growth.
Macrosomia can lead to complications during delivery, such as shoulder dystocia, and can increase the risk of injury to both the mother and the baby. While low birth weight and preterm birth are also potential complications of GDM, macrosomia is considered the greatest risk to the fetus if euglycemia is not maintained. Cleft palate is not typically associated with GDM.
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