A client with an electrical burn injury is admitted.
What is a critical aspect of initial assessment?
Monitor cardiorespiratory status.
Assess circulation to extremities.
Evaluate electrolyte balance.
Check for signs of infection.
The Correct Answer is A
Choice A rationale
Monitoring cardiorespiratory status is the highest priority for an electrical burn patient because electricity frequently causes cardiac arrhythmias or arrest. The heart's electrical conduction system is extremely sensitive to external currents, which can trigger ventricular fibrillation. Additionally, the path of the current can cause respiratory paralysis or delayed cardiac issues. Immediate and continuous EKG monitoring is essential to detect and treat life-threatening dysrhythmias that may not be immediately apparent upon initial physical inspection of the skin.
Choice B rationale
Assessing circulation to the extremities is important because electrical burns can cause internal tissue damage and swelling, leading to compartment syndrome. However, this is secondary to the immediate threat of cardiac arrest. While the nurse must check peripheral pulses and capillary refill to ensure the limbs are perfused, the systemic stabilization of the heart and lungs takes precedence. Compartment syndrome is a serious complication, but it develops over hours, whereas cardiac rhythm disturbances can be fatal instantly.
Choice C rationale
Evaluating electrolyte balance is necessary because extensive tissue damage from an electrical burn releases large amounts of potassium into the bloodstream, potentially causing hyperkalemia. Normal potassium ranges are 3.5 to 5.0 mEq/L. While hyperkalemia can lead to cardiac issues, the direct effect of the electrical current on the heart's conduction is the more immediate concern. Electrolyte monitoring is a vital part of the ongoing management but follows the initial assessment of the patient's active heart rhythm.
Choice D rationale
Checking for signs of infection is a long-term management goal rather than a critical aspect of the initial assessment. Infection usually takes days to develop. In the immediate aftermath of an electrical injury, the focus must be on the invisible internal damage caused by the current's path through the body. Although skin entry and exit wounds should be cleaned, the life-threatening risks are physiological and internal, necessitating a focus on vital organ function and hemodynamic stability.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Referring the client to the provider is a deflection that fails to provide immediate education or address the client's stated confusion. While the provider ultimately diagnoses the condition, the nurse has an independent role in patient education and health promotion. A competitive gymnast requires specific information regarding the mechanics of their injury. Simply deferring the question misses a critical opportunity to build rapport and begin the teaching process regarding activity modification and bone health.
Choice B rationale
This response is non therapeutic and speculative, potentially making the client feel defensive or misunderstood. Stress fractures are typically not the result of a single traumatic event like a fall from a balance beam; rather, they are the result of cumulative microtrauma. Asking about a fall demonstrates a lack of understanding regarding the pathophysiology of stress fractures. The nurse should focus on the chronic nature of the injury rather than searching for an acute traumatic cause.
Choice C rationale
Stress fractures occur when repetitive loading forces exceed the structural capacity of the bone to remodel itself. In gymnastics, high impact landings and repetitive routines create cyclical loading that leads to microfractures. When the rate of bone breakdown by osteoclasts outpaces the rate of bone formation by osteoblasts, a fracture occurs. This explanation directly addresses the client's activity level and provides a scientific basis for why the injury persists despite the lack of a single traumatic event.
Choice D rationale
This statement is scientifically inaccurate as stress fractures are specifically defined by their non traumatic, overuse origin. High falls typically result in acute, displaced fractures or commuted injuries rather than the hairline stress fractures common in athletes. Attributing the injury to falls misleads the client about the risks associated with their sport. Proper education should emphasize that it is the frequency and intensity of normal training, not accidental falls, that leads to these specific types of skeletal failures.
Correct Answer is C
Explanation
Choice A rationale
Monitoring for signs of infection is a standard postoperative nursing action that involves assessing the incision for erythema, warmth, edema, and purulent drainage. While vital for detecting complications like surgical site infections, it is not the primary intervention for preventing skin breakdown. Skin breakdown is more directly related to mechanical forces such as pressure, friction, and shear rather than the inflammatory or bacterial processes associated with a localized incisional infection.
Choice B rationale
Administering anticoagulants such as heparin or enoxaparin is essential for preventing deep vein thrombosis and pulmonary embolism following major orthopedic surgery. These medications modify the coagulation cascade to inhibit thrombus formation during periods of immobility. However, anticoagulation therapy does not directly address the risk of pressure ulcers or skin integrity. Preventing skin breakdown requires physical interventions that redistribute pressure and manage the microclimate of the skin surface during the recovery phase.
Choice C rationale
Maintaining hip abduction using pillows or an abduction wedge is the priority intervention to ensure proper joint alignment and prevent prosthesis dislocation. In terms of skin integrity, properly aligned pillows also help in distributing weight and preventing the knees or ankles from rubbing together, which reduces the risk of pressure injury. Maintaining the prescribed position ensures that the soft tissues around the surgical site are not subjected to unnecessary tension or compressive forces during repositioning.
Choice D rationale
Encouraging early ambulation is a critical component of postoperative recovery that helps prevent many complications, including pneumonia and venous stasis. While moving the patient helps relieve pressure on the skin over bony prominences, the specific priority in the immediate post-arthroplasty period is maintaining the stability of the new joint. Ambulation must be balanced with the need for strict alignment protocols to ensure the surgical repair remains intact while the surrounding musculature and skin heal.
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