A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.

Which of the following interventions should the nurse perform first?

Administer pain medication.

Administer a tetanus booster.

Clean and dress the wound.

Administer IV fluids.

Answer and Explanation

The Correct Answer is D

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

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Correct Answer is B

Explanation

Choice A rationale:
Examining feet daily is important for preventing complications related to peripheral neuropathy, not retinopathy or nephropathy.
Choice B rationale:
Maintaining stable blood glucose levels can help prevent microvascular complications such as retinopathy and nephropathy.
Choice C rationale:
Annual eye examinations are important, but they do not prevent retinopathy.
Choice D rationale:
Wearing compression stockings daily is not directly related to preventing retinopathy or nephropathy.

A. Trim the nails at the lateral corners. B. Clean under the nail with an orange stick. C. File the nails in a rounded shape. D. Push the cuticles back with a metal nail file.

Correct Answer is C

Explanation

Choice A rationale:
Trimming the nails at the lateral corners can lead to ingrown toenails, which can cause pain and infection.
Choice B rationale:
Cleaning under the nail with an orange stick can cause injury to the nail bed and lead to infection.
Choice C rationale:
Filing the nails in a rounded shape can prevent injury and is the recommended method for nail care.
Choice D rationale:
Pushing the cuticles back with a metal nail file can cause injury and infection.

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A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities. Which of the following interventions should the nurse perform first?

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Correct Answer is C

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A nurse in the emergency department is caring for a client who has a 30% burn injury to her lower extremities.

Which of the following interventions should the nurse perform first?