A client with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?
Assess oral temperature.
Place on cardiac monitor.
Check a potassium level.
Assess for pain at contact points.
The Correct Answer is B
A. Assessing oral temperature is not a priority immediately after an electrical burn, as the focus should be on monitoring for cardiac issues and other life-threatening conditions.
B. Electrical burns can cause cardiac arrhythmias, including dysrhythmias like ventricular fibrillation, which can be life-threatening. The nurse should place the client on a cardiac monitor immediately to detect any abnormal rhythms and respond accordingly.
C. While checking potassium levels is important for assessing potential complications such as kidney damage or arrhythmias, cardiac monitoring should take precedence.
D. Assessing for pain at contact points is important, but it is secondary to ensuring cardiac stability in an electrical burn victim.
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Related Questions
Correct Answer is D
Explanation
A. Potassium chloride is used to treat hypokalemia, not as a warfarin antidote.
B. Vitamin E does not counteract warfarin’s effects and may increase bleeding risk.
C. Protamine sulfate is the antidote for heparin, not warfarin.
D. Vitamin K is the appropriate antidote for excessive warfarin, as it promotes the synthesis of clotting factors inhibited by warfarin.
Correct Answer is D
Explanation
A. Hypercalcemia (Calcium > 10.5 mg/dL) can lead to shortened QT intervals, not prolonged ones, and is unlikely to cause Torsades de Pointes.
B. A magnesium level of 3.1 mEq/L is slightly elevated and would not contribute to QT prolongation or Torsades de Pointes. In fact, magnesium supplementation is a treatment for this condition.
C. Hypokalemia (Potassium < 3.5 mEq/L) can prolong the QT interval and contribute to dysrhythmias, but it is less commonly a direct cause of Torsades de Pointes compared to hypomagnesemia. A potassium level of 2.6 mEq/L is low but would not typically result in Torsades without coexisting hypomagnesemia.
D. Hypomagnesemia (Magnesium < 1.5 mEq/L) disrupts the heart's electrical activity, prolonging the QT interval and increasing the risk of polymorphic ventricular tachycardia, like Torsades de Pointes. Magnesium is critical for stabilizing myocardial electrical conduction, and a value of 1.1 mEq/L indicates significant deficiency, consistent with this dysrhythmia.
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