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.
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Related Questions
Correct Answer is D
Explanation
A) Instructing the client to sit on a rubber ring may provide comfort for those with hemorrhoids or perineal discomfort but is not directly related to managing hemiplegia.
B) Raising the head of the client's bed to a 90° angle may be uncomfortable and may not address the specific needs related to hemiplegia.
C) Using moisturizing lotion while massaging the client's bony prominences is important for skin integrity but does not directly address the positioning needs of a client with hemiplegia.
D) Placing pillows between the client's knees when in a side-lying position helps maintain proper alignment, prevents pressure ulcers, and promotes comfort for the client with hemiplegia.
Correct Answer is B
Explanation
A) Offering reassurance about the outcome of the procedure may not address the client's specific fears.
B) Encouraging the client to discuss their concerns allows the nurse to address any misconceptions or fears the client may have and provide appropriate information and support.
C) Assuming the client's fear is related to needles may not be accurate and may not address their specific concerns.
D) Asking the client to explain why they are scared is a good approach, but it may not immediately address their fears or provide the support they need.
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