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 B

Explanation

The infant's symptoms are consistent with postoperative pain, which can be expected following a surgical procedure like pyloromyotomy. The PN should administer the prescribed analgesic medication to relieve the infant's discomfort and pain. It is crucial to manage pain appropriately in infants to promote healing, improve feeding tolerance, and prevent complications.

Option A is not appropriate as the infant's symptoms are not indicative of hypoglycemia.

Option C is not appropriate as the infant's symptoms do not indicate hypothermia.

Option D is not appropriate as the infant's symptoms do not indicate dehydration.

A. Current administration of analgesics or antianxiety medications. B. History of situational depression related to major life events. C. Previous episodes of frequent falls. D. The client's history of alcohol abuse.

Correct Answer is A

Explanation

The practical nurse (PN) should obtain information about the client's current medications, including any analgesics or antianxiety medications that may be contributing to the confusion. These medications can cause cognitive impairment and confusion, especially in older adults. It is important to assess the client's mental status and identify any potential causes of confusion, as this can indicate a change in the client's condition that requires further evaluation and intervention.

Option B is incorrect as it refers to a history of situational depression, which may not be relevant to the current situation.

Option C is also incorrect as it refers to previous falls, which may not be related to the current confusion.

Option D is incorrect as it refers to the client's history of alcohol abuse, which may be important to know but is not the most relevant information to obtain in this situation.

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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

The practical nurse (PN) caring for a 3-month-old boy one day after a pyloromyotomy notices that the infant is restless, is exhibiting facial grimaces, and is drawing his knees to his chest. What action should the PN take?

Correct Answer is B

Explanation

An older female client is admited to the orthopedic unit following surgical repair of a fractured hip. On the second postoperative day, the client becomes confused and repeatedly asks the practical nurse (PN) where she is. Which information should the PN obtain before reporting to the charge nurse?

Correct Answer is A

Explanation

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