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 first intervention the PN should implement is to **sit and offer to listen to the client's concerns**. It is important to approach the client in a calm and non-threatening manner and to establish a rapport with him. Offering to listen to his concerns can help the client feel heard and understood, and can help build trust between the client and the PN.
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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