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 D

Explanation

Choice A rationale:
While hypertension is a risk factor for stroke, it is modifiable through lifestyle changes and medication.
Choice B rationale:
Smoking is a modifiable risk factor for stroke. Quitting smoking can significantly reduce the risk of stroke.
Choice C rationale:
Obesity is a modifiable risk factor for stroke. Weight loss and maintaining a healthy weight can reduce the risk of stroke.
Choice D rationale:
Genetics is a nonmodifiable risk factor for stroke. Individuals with a family history of stroke are at a higher risk, and this cannot be changed.

A. Change the IV site dressing every 4 days. B. Obtain the client's blood glucose every 12 hr. C. Weigh the client every other day. D. Change the IV tubing every 24 hr.

Correct Answer is D

Explanation

Choice A rationale:
The IV site dressing should be changed every 7 days, not every 4 days.
Choice B rationale:
The client’s blood glucose should be monitored every 4-6 hours, not every 12 hours.
Choice C rationale:
The client should be weighed daily, not every other day.
Choice D rationale:
The IV tubing for TPN should be changed every 24 hours to prevent 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?