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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The practical nurse (PN) should first massage the fundus and expel retained lochia and clots to help the uterus contract and prevent postpartum hemorrhage.
Taking the vital signs and opening the IV infusion rate of oxytocin (A) may be necessary but not as urgent as massaging the fundus.
Notifying the registered nurse (RN) that the client's bladder is distended (B) is not relevant to addressing the client's boggy and displaced fundus.
Putting the infant to breast to suckle and stimulate oxytocin secretion (C) is a valid intervention, but it is not the first priority when the client's fundus becomes boggy and displaced above the umbilicus.
Correct Answer is B
Explanation
The best indicator to the practical nurse (PN) that the community bicycle safety education program was effective is that the number of students wearing bicycle helmets increased by 10%. Wearing a helmet while riding a bicycle is an important safety measure that can help prevent head injuries in the event of an accident. An increase in the number of students wearing helmets indicates that the program was successful in promoting this safety behavior. The other findings listed may also provide useful information about the effectiveness of the program, but the increase in helmet use is the most direct and measurable indicator of success.
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