What is the first nursing action?

Posted by: Pdfprep Category: NCLEX-RN Tags: , ,

An 11-year-old boy has received a partial-thickness burn to both legs. He presents to the emergency room approximately 15 minutes after the accident in excruciating pain with charred clothing to both legs. 

What is the first nursing action?
A . Apply ice packs to both legs.
B . Begin débridement by removing all charred clothing from wound.
C . Apply Silvadene cream (silver sulfadiazine).
D . Immerse both legs in cool water.

Answer: D


(A) Ice creates a dramatic temperature change in the tissue, which can cause further thermal injury.

(B) Charred clothing should not be removed from wound first. This creates further tissue damage. Débridement is not the first nursing action.

(C) Applying silver sulfadiazine cream first insulates heat in injured tissue and increases potential for infection.

(D) Emergency care of a thermal burn is immersing both legs in cool water. Cool water permits gradual temperature change and prevents further thermal damage.

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