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

Left arm (entire): 9%

Anterior chest: 18%

Total: 9% + 18% = 27%

A. Assessing the client's support system B. Assessing and removing any rings or jewelry from affected limb C. Assessing the client's circulation distal to the burn site D. Assessing the client's urine output E. Assessing the client's respiratory function

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

Explanation

A. Assessing the client's support system: Important in overall care, but not a priority in the acute phase.

B. Assessing and removing any rings or jewelry from affected limb: Jewelry can cause constriction due to swelling; removing it prevents further vascular compromise.

C. Assessing the client's circulation distal to the burn site: Circumferential burns can compromise perfusion due to edema or eschar formation. Checking pulses, cap refill, and sensation is essential.

D. Assessing the client's urine output: Important in systemic burns, but not directly related to a localized forearm burn.

E. Assessing the client's respiratory function: Critical in burns involving the face or inhalation injury, but not the forearm.

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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

A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

Correct Answer is C

Explanation

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

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

Explanation

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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?

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