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
A male client with paranoia can be expected to exhibit behavior such as being **openly hostile to others for no apparent reason**. Paranoia is a mental health condition characterized by intense and irrational mistrust or suspicion of others. This can lead to hostility and aggression towards others, even when there is no apparent reason for it.
Correct Answer is A
Explanation
Baclofen is a muscle relaxant that can help relieve muscle spasms and manage conditions such as cerebral palsy¹. An assessment finding that indicates the drug is effective for a child with cerebral palsy would be decreased muscular spasticity. This means that the child's muscles are less stiff and rigid, which can improve their mobility and overall quality of life.
The other choices are incorrect because they are not directly related to the therapeutic effects of baclofen. Baclofen is a muscle relaxant that is used to relieve muscle spasms and stiffness. While it may have other effects on the body, its primary therapeutic effect is to decrease muscular spasticity.
- Increased appetite is not a known effect of baclofen.
- Sufficient urinary output is important for overall health, but it is not directly related to the effectiveness of baclofen.
- Fewer temper outbursts may be an indirect result of decreased muscular spasticity and improved mobility, but it is not a direct effect of baclofen.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today