A 31-year-old male patient with burn injuries is admitted to the burn unit. Which priority does the nurse anticipate within the first 24 hours?
Sterile dressing changes
Emotional support
Fluid resuscitation
Range-of-motion exercises
The Correct Answer is C
In the initial 24 hours after burn injury, fluid resuscitation is a critical priority in the management of burn patients. Burn injuries can lead to significant fluid loss, both locally at the burn site and systemically due to increased capillary permeability. Fluid resuscitation aims to restore and maintain adequate intravascular volume, ensuring sufficient tissue perfusion and organ function.
The Parkland Formula is commonly used to guide fluid resuscitation in burn patients. It involves calculating the total volume of fluid needed in the first 24 hours, with a portion given in the initial hours after injury and the remainder given over the remaining hours.
A. Sterile dressing changes (option A) are incorrect because they are important in wound care management for burn patients to prevent infection. However, fluid resuscitation takes precedence within the first 24 hours.
B. Emotional support (option B) is incorrect because it is an essential aspect of burn care, as burn injuries can have a significant psychological impact. While emotional support is crucial for the patient's overall well-being, it may not be the highest priority within the first 24 hours compared to addressing the physiological needs of fluid resuscitation.
D. Range-of-motion exercises (option D) are incorrect because they are important for preventing contractures and maintaining joint mobility in burn patients. However, they are typically initiated after the initial fluid resuscitation phase and wound stabilization.
Therefore, the priority the nurse anticipates within the first 24 hours for a 31-year-old male patient with burn injuries is fluid resuscitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["21"]
Explanation
flow rate for an infusion= (Volume in mL * Drop factor) / Time in minutes.
volume of the infusion bag is 250 mL, the drop factor is 10 gtts/mL, and the time is 2 hours, which is 120 minutes.
(250 mL * 10 gtts/mL) / 120 minutes = 2500 gtts / 120 minutes ≈ 20.83 gtts/minute. Therefore, the nurse should run the infusion at a rate of approximately 21 drops per minute to deliver 1 unit of packed red blood cells over the 2-hour period.
Correct Answer is D
Explanation
Arterial pressure monitoring involves the insertion of an arterial catheter, typically in the radial artery, to directly measure blood pressure. Complications can arise from this invasive procedure, and one potential complication is inadequate blood flow to the hand, leading to numbness or ischemia.
A. The Allen's test is positive in (option A) is incorrect because The Allen's test is performed before arterial catheter insertion to assess the collateral circulation of the hand. A positive Allen test indicates adequate collateral circulation, which is desirable before performing the procedure. However, it does not directly indicate a complication during or after arterial pressure monitoring.
B. The mean arterial pressure (MAP) is 90 mm Hg in (option B) is incorrect because The mean arterial pressure (MAP) represents the average pressure in the arterial system during one cardiac cycle. While changes in MAP can be significant for patient management, it does not specifically indicate a complication of arterial pressure monitoring.
C. The dicrotic notch visible in the waveform in (option C) is incorrect because The dicrotic notch represents the closure of the aortic valve and is a normal finding in arterial waveforms. Its presence does not indicate a complication.
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