A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?
Assessing psychosocial coping
Adequate fluid resuscitation
Provide nutritional support
Mitigating risk of infection
The Correct Answer is B
A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.
B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.
C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.
D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "You have a genetic tendency for the development of anemia.”: Anemia in CKD is primarily due to impaired erythropoietin production, not genetics.
B. "The increased metabolic waste products in your body depress the bone marrow and cause anemia.”: While uremic toxins may have some marrow-suppressive effects, the main cause is lack of erythropoietin.
C. "There is a decreased production by the kidneys of the hormone erythropoietin which is the cause of your anemia.”: In CKD, damaged kidneys produce less erythropoietin, leading to reduced RBC production and anemia.
D. "You are not eating enough iron-rich foods, which is causing anemia.”: Although iron deficiency can contribute, this is not the primary cause in CKD-related anemia.
Correct Answer is D
Explanation
Formula: 4 mL × Body weight (kg) × %TBSA
4 × 100 × 40 = 16,000 mL total in 24 hours
Half (8,000 mL) is given in the first 8 hours
Answer- 8000ml
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