A client is admitted to the ED with a burn injury. The client’s vital signs are the following: blood pressure: 72/48, heart rate: 152 beats/min, respiratory rate: 26/min. He is pale in color and the nurse is unable to feel his pedal pulses. Which action will the nurse take first?

Choice A reason: Encouraging fluid intake is inappropriate post-hemodialysis, as fluid overload is a risk. A fever of 101.2°F requires provider notification, making this incorrect, as it’s unsafe compared to the nurse’s priority of addressing a potential infection promptly.

Choice B reason: Monitoring vital signs is useful but doesn’t address the urgency of a 101.2°F fever post-hemodialysis, which may indicate infection. Notifying the provider is critical, making this incorrect, as it delays the nurse’s action to manage a serious complication.

Choice C reason: Notifying the provider is most appropriate for a fever of 101.2°F post-hemodialysis, as it may signal infection, a serious complication. This aligns with post-dialysis care priorities, making it the correct action for the nurse to take immediately.

Choice D reason: Monitoring the shunt site is relevant but less urgent than notifying the provider about a fever, which may indicate systemic infection. This is incorrect, as it delays the nurse’s priority of addressing the client’s elevated temperature post-hemodialysis.

Choice A reason: Restricting fluids is contraindicated in burns, as hypovolemia requires aggressive fluid resuscitation. Administering lactated Ringer’s is correct, making this incorrect, as it’s unsafe compared to the nurse’s priority to restore volume in a burn-injured client.

Choice B reason: Dextrose 5% is not used for burn resuscitation, as it lacks electrolytes needed for fluid shifts. Lactated Ringer’s is standard, making this incorrect, as it’s inappropriate compared to the nurse’s focus on proper fluid therapy for burn management.

Choice C reason: Administering oxygen addresses potential airway compromise and hypoxia from facial and chest burns. This aligns with burn care priorities, making it a correct action the nurse would implement to ensure respiratory stability in the emergency department.

Choice D reason: A cooling blanket is not standard for partial-thickness burns; cooling is brief and initial. Elevating extremities reduces edema, making this incorrect, as it’s not a priority action compared to the nurse’s focus on burn injury management.

Choice E reason: Elevating extremities without fractures reduces edema in burned arms, improving circulation. This aligns with burn care protocols, making it a correct action the nurse would implement to manage swelling in the client with partial-thickness burns.

Choice F reason: Oral pain medication is contraindicated with facial burns due to airway risks and absorption issues. IV lactated Ringer’s is appropriate, making this incorrect, as it’s unsafe compared to the nurse’s priority for pain management in burns.

Choice G reason: Administering lactated Ringer’s 1 L bolus restores fluid volume in burn-induced hypovolemia, per resuscitation protocols. This is a correct action the nurse would implement to stabilize the client with partial-thickness burns in the emergency department.