Nokea
The nurse cares for a 29-year-old male in the emergency department (ED)
Item 4 of 6
Nurses' Note
Vital Signs
Assessment
2115: Client brought by emergency medical services (EMS) for a thermal burn injury while setting up a fire outside. His right arm caught fire as some of the lighter fluid he used was on his sweater. The fire then spread to his back and part of his chest. The client has sustained full- thickness burns to his right hand and entire arm. Deep partial thickness burns were observed to his right torso and entire back. The client arrives screaming in pain rating it as 9 on a scale of 0 (no pain) to 10 (severe pain). He endorses no pain in his right arm or hand, stating it feels 'numb.' EMS started a 16-gauge peripheral vascular access device in the left antecubital space.
Click to specify the interventions the nurse anticipates incorporating into the client's care plan
Correct Answer: A, D, E
Rationale: Inserting a urinary catheter monitors fluid resuscitation, removing jewelry prevents constriction, and tetanus prophylaxis prevents infection. Cool saline is avoided as it can cause hypothermia, and fluid restrictions are inappropriate.