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.

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A) Elevated iron levels are directly related to hemochromatosis and could indicate a worsening condition if they continue to rise, as this condition causes iron to accumulate in the body, leading to further liver damage.
B) An increased albumin level could be a sign of potential improvement, as low albumin levels are common in liver disease due to the liver's reduced ability to synthesize proteins.
C) A productive cough may be unrelated to the diagnosis of cirrhosis but could be indicative of an additional respiratory issue that needs to be addressed.
D) Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis and would suggest a potential worsening of the condition.
E) Hematemesis is a serious symptom often associated with advanced liver disease and significant bleeding in the gastrointestinal tract, indicating a potential worsening of the patient's condition.
F) Spontaneous bruising can occur due to decreased production of clotting factors by the liver, also suggesting a worsening condition.

A. Increase the client's ventilator flow rate. B. Empty water from the client's ventilator tubing. C. Evaluate the client for a cuff leak. D. Suction the client's airway.

Correct Answer is C

Explanation

A) Increasing the ventilator flow rate may not address the cause of the low-pressure alarm and could potentially worsen the situation.
B) Emptying water from the ventilator tubing is not typically necessary when the low-pressure alarm sounds.
C) Evaluating the client for a cuff leak is essential because a leak in the endotracheal tube cuff can cause the low-pressure alarm to sound.
D) Suctioning the client's airway is not indicated unless there are signs of airway obstruction or secretions.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"B"}}

Explanation

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds on the ventilator. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

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