Difficulty: Medium
Average Score: 76%
Simulated
A client who suffered an electrical injury with the entrance site on the left hand and the exit site on the left foot is admitted to the burn unit. Which intervention is most important for the nurse to include in this client's plan of care (POC)?
Correct answer
D
Rationale
Electrical injuries can cause cardiac arrhythmias due to the current passing through the heart. These arrhythmias may be immediate or delayed, making continuous cardiac monitoring essential for at least 24 hours. While respiratory assessment, neurological evaluation, and range of motion are important components of care, cardiac monitoring takes priority due to the risk of fatal arrhythmias.