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

Based on the assessment findings, the infant is at the greatest risk for developing anemia due to a lack of iron. Infants should begin eating solid foods that are rich in iron at around 6 months of age to ensure they are getting enough of this important nutrient. Drinking whole milk from a bottle can displace other foods that are rich in iron and contribute to the development of anemia.

Option A, allergies related to whole milk, is a possibility but not the greatest risk in this situation.

Option C, obesity due to increased calorie count, is also a possibility but not the greatest risk.

Option D, lactose intolerance due to whole milk, is a possibility but not the greatest risk in this situation.

A. Explain the unit rules to ensure his safety. B. Gather required admission information. C. Have the client put personal items away. D. Sit and oﬀer to listen to the client's concerns.

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.

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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

During a well-baby clinic visit, a mother tells the practical nurse (PN) that her 12-month-old infant is not yet eating solid foods and drinks whole milk from a bottle. Based on these assessment findings, this infant is at the greatest risk for developing which condition?

Correct Answer is B

Explanation

A male client with paranoia has been admitted to the mental health unit, and upon arrival, he immediately goes to the corner of the room and sits quietly without communicating. In approaching the client, what intervention should the practical nurse (PN) implement first?

Correct Answer is D

Explanation

A client with a major depressive disorder is admitted to the inpatient psychiatric unit. Which intervention should the practical nurse (PN) use to demonstrate support of the client?

A client at 8-weeks gestation has a hemoglobin of 9.5 mg/dl. The healthcare provider prescribes an oral iron supplement. Which information should the practical nurse (PN) provide the client?

The practical nurse (PN) is caring for a 4-year-old girl with a moderate developmental disability. Which is the primary goal of treatment for a child with a developmental disability?

When changing a diaper on a 2-day-old infant, the practical nurse (PN) observes that the baby's legs are ﬂexed with limited abduction. Based on this finding, what action should the PN take next?

A primigravida who is at 10-weeks gestation is hospitalized on the antepartum unit for pyelonephritis. The client tells the practical nurse (PN) that she has had several episodes of nausea. When reviewing her lunch menu, which food should the PN discourage her from choosing?

The father of a newborn asks the practical nurse (PN) why an injection is being given to his baby. Which response by the PN best explains the purpose of administering Phyto menadione injectable to newborns?

The practical nurse (PN) is caring for a postpartum client who delivered 5 hours ago and has saturated a perineal pad with a few clots within 15 minutes. Which action is most important for the PN to implement?

The practical nurse (PN) is caring for a 3-month-old infant with a head injury who had a seizure episode. The infant has a high-pitched cry and is irritable. The caregiver reports that the infant rolled over and fell onto the carpeted ﬂoor. Which action should the PN take?