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 B
Explanation
Mean arterial pressure (MAP) is a measure of the average pressure within the arteries during one cardiac cycle. It represents the perfusion pressure that drives blood flow to organs and tissues. MAP is calculated using the formula:
MAP = Diastolic blood pressure + 1/3 (Systolic blood pressure - Diastolic blood pressure)
Blood loss, particularly in cases of significant hemorrhage, leads to a decrease in blood volume. When blood volume decreases, there is less circulating blood available to generate pressure within the arterial system. This reduction in blood volume results in decreased MAP.
Therefore, in the case of massive blood loss after trauma, the student can correlate it with a lower blood volume, which in turn leads to a lower MAP. The decrease in blood volume reduces the perfusion pressure, compromising organ and tissue perfusion
A. It causes vasoconstriction and increased MAP in (option A) is incorrect because: While vasoconstriction can occur as a compensatory mechanism to maintain blood pressure, it does not necessarily lead to an increased MAP in the context of significant blood loss.
C. It raises cardiac output and MAP in (option C) is incorrect because Blood loss typically leads to a reduction in cardiac output due to decreased blood volume. Therefore, it does not raise cardiac output and MAP.
D. There is no direct correlation to MAP in (option D) is incorrect because: There is indeed a direct correlation between blood loss and MAP. As blood volume decreases, MAP decreases as well.
Therefore, the correct correlation between blood loss and MAP is that lower blood volume lowers MAP.
Correct Answer is A
Explanation
Premature ventricular contractions (PVCs) are abnormal heart rhythms originating from the ventricles. They can be triggered by various factors, including irritation or stimulation of the airway during suctioning.
In this situation, the priority is to ensure adequate oxygenation and ventilation for the patient. Stopping the suctioning procedure and providing ventilatory support with 100% oxygen helps maintain oxygen levels and minimizes further cardiac dysrhythmias.
B. Check the patient's potassium level in (option B) is incorrect because While electrolyte imbalances, including low potassium levels (hypokalemia), can contribute to cardiac dysrhythmias, checking the potassium level is not the immediate priority when PVCs occur during suctioning.
C. Give prescribed PRN antidysrhythmic medications in (option C) is incorrect because: Administering antidysrhythmic medications without further assessment or evaluation may not be appropriate in this situation.
D. Decrease the suction pressure to 80 mm Hg in (option D) is incorrect because: While adjusting suction pressure may help prevent further irritation, it is not the initial priority when PVCs are present during suctioning.
E. Documenting the dysrhythmia in the patient's chart in (option E) is incorrect because: Documentation is important but should not be the initial action when a patient experiences PVCs during suctioning. Patient safety and immediate intervention take precedence.
Therefore, when PVCs occur during suctioning, the nurse should stop the procedure, provide ventilatory support with 100% oxygen, and assess the patient's response to intervention.
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