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

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Auscultate the antecubital fossa using a Doppler stethoscope: The graft is located in the forearm, not the antecubital fossa.

B. Measure the client's blood pressure to ensure it is higher in the left arm than the right: This does not assess AV graft patency and blood pressure should be avoided in the arm with a graft.

C. Auscultate the site for a bruit: The presence of a bruit and thrill indicates blood flow through the graft, confirming patency.

D. Check the brachial and radial pulses of the left arm simultaneously: While peripheral pulses can offer some insight, they do not directly confirm graft patency.

A. Muscle layers B. Epidermal layers C. Dermal layers D. Subcutaneous layers E. Bone and ligaments

Correct Answer is ["A","B","C","D"]

Explanation

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is ["A","B","C","D"]

Explanation

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