A nurse in the emergency department is managing the care of a client who has an electrical shock injury. Which of the following actions should the nurse take first?
Change dressings over the entrance and exit wounds.
Obtain an ECG.
Administer an opioid pain medication.
Titrate IV fluids to maintain urine output at 75 mL/hr.
The Correct Answer is B
A. Changing dressings is important but not the priority over assessing cardiac status in an electrical shock injury.
B. Obtaining an ECG is the priority to assess for any cardiac dysrhythmias, which can be immediate and life-threatening consequences of electrical shock injuries.
C. Administering pain medication can be done once the client's cardiac status has been evaluated and stabilized.
D. While maintaining adequate urine output is important, assessing cardiac status takes precedence.
Nursing Test Bank
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Related Questions
Correct Answer is B
Explanation
A) Using a communication board with colored pictures might not effectively facilitate communication for someone who primarily uses sign language.
B) Requesting an interpreter during the initial assessment ensures effective communication between the nurse and the client.
C) Familiarizing themselves with commonly used signed language may help the nurse in the long term but may not be feasible or effective during the immediate admission process.
D) Asking a family member to be present during the admission may help but may not provide the necessary communication support for effective assessment and care.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"C"}}
Explanation
A) Metoprolol is a beta-blocker that can help reduce heart rate and blood pressure, which is beneficial in cases of chest pain and irregular tachycardia.
B) Oxygen at 2 L/min via nasal cannula is anticipated because the client's oxygen saturation is below normal, indicating they may benefit from supplemental oxygen.
C) Drawing electrolytes along with Hgb and Hct is anticipated as it is important to monitor these levels due to the client's symptoms and history of hypertension and diabetes.
D) Morphine is anticipated because the client reports pain, and morphine can provide pain relief and reduce the workload on the heart.
E) Nitroglycerin is a standard treatment for chest pain due to its vasodilating effects, which can improve blood flow to the heart.
F) Obtaining daily weight is nonessential at this moment because it does not directly address the acute symptoms the client is experiencing.
G) Atropine is contraindicated as the client's heart rate is tachycardic, not bradycardic, and atropine is used to increase heart rate.
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