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.

Answer and Explanation

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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Correct Answer is C

Explanation

A. Blood glucose elevation is a concern for statins, but it is not a primary reason for questioning the order.

B. A history of high cholesterol is common and would not trigger concern regarding lovastatin.

C. Lovastatin can cause liver toxicity, so elevated liver enzymes are a contraindication or cause for concern when prescribing this medication. The nurse should verify this before starting the medication.

D. A history of peptic ulcers is unrelated to the use of lovastatin and would not be a concern in this case.

A. Encourage the client to sit up at the bedside in a chair and lean forward. B. Have the client rest in bed with the head elevated 15 to 20 degrees. C. Place the client in the Trendelenburg position with pillows behind the head. D. Ask the client to rest in bed in a high- Fowlers position with the knees flexed.

Correct Answer is A

Explanation

A. Sitting up and leaning forward helps improve lung expansion and ventilation, which is beneficial for clients with COPD.

B. Elevating the head is helpful but not as effective as sitting upright for COPD clients who need to improve their ventilation.

C. The Trendelenburg position is not appropriate for improving ventilation in COPD patients.

D. While high-Fowler's may help in some situations, having the knees flexed can restrict the diaphragm and limit breathing capacity.

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A client with extensive electrical burn injuries is admitted to the emergency department. Which prescribed intervention should the nurse implement first?

Nursing Test Bank

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