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 B

Explanation

A) Skin breakdown could occur due to the catheter bag lying in bed, but it is not the primary risk associated with the observations noted.
B) A kinked IV tubing can lead to stasis of fluids, which increases the risk of infection. Additionally, if the urinary catheter bag is not positioned below the level of the bladder, urine can reflux back into the bladder, which also increases the risk of infection.
C) Neurogenic bladder is a condition typically associated with nerve damage, not directly related to the position of the catheter bag or kinked tubing.
D) Phlebitis is inflammation of a vein, which would not be directly caused by the issues noted with the urinary catheter.

A. Administer the transfusion through a 25-gauge saline lock. B. Administer the plasma immediately after thawing. C. Transfuse the plasma over 4 hr. D. Hold the transfusion if the client is actively bleeding.

Correct Answer is B

Explanation

A) Administering the transfusion through a 25-gauge saline lock might not be appropriate as it may cause hemolysis or obstruct the flow of plasma.
B) Administering the plasma immediately after thawing is crucial to ensure the effectiveness of the transfusion and to prevent degradation of the plasma components.
C) Transfusing the plasma over 4 hours is a standard practice, but the priority is administering it promptly after thawing.
D) Holding the transfusion if the client is actively bleeding is inappropriate since the client is losing blood which needs to be replaced. Furthermore, fresh frozen plasma contains clotting factors which are beneficial for a client whose cause of bleeding is clotting factor deficiencies.

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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

A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?

Correct Answer is B

Explanation

A nurse is preparing to administer fresh frozen plasma to a client. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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