The nurse is a first responder to the scene of a motor vehicle accident in which the patient experienced burns to 35% of her body. Which action does the nurse take first?

Remove the patient’s clothing, shoes, and jewelry. The first action typically performed by first responders for a burn patient is to remove their clothing and jewelry to stop further damage that may be caused by burning clothing and accessories. Once the burning has stopped, the nurse can assess the patient’s perfusion. Tepid water is used to rinse the burns, not cool water, as cool water can cause tissue damage and hypothermia. The nurse should not elevate the patient’s head until it is determined the patient has not sustained a cervical spine injury. IV access and fluid hydration will be important, but after other steps in the response.

The nurse is a first responder to the scene of a motor vehicle ac...

Category: Physiological Adaptation
Difficulty: 5

Topics: Delegation, Prioritization and Leadership Inflammation Medication and Blood Products Routes of Administration Tissue Integrity

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