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 B

Explanation

A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.

B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.

C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.

D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.

A. Bleeding may occur at injection sites when the intramuscular route is used. B. The client can experience nausea and vomiting when given oral medications. C. Pain resulting from a burn injury requires relief by the fastest route available. D. Damaged tissue and edema may interfere with drug absorption via other routes.

Correct Answer is D

Explanation

A. Bleeding may occur at injection sites when the intramuscular route is used: While possible, this is not the primary concern.

B. The client can experience nausea and vomiting when given oral medications: This may be true but is secondary to absorption issues.

C. Pain resulting from a burn injury requires relief by the fastest route available: Although IV is fast, the key issue is absorption.

D. Damaged tissue and edema may interfere with drug absorption via other routes: Burned and edematous tissue reduces IM and subcutaneous absorption, making IV the preferred route.

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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 caring for a client receiving a hemodialysis treatment. Which of the following complications should the nurse recognize when the client becomes restless and reports nausea and headache?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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