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 D
Explanation
A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.
B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.
C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.
D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Explanation
Critical to assess: A. Airway patency and signs of inhalation injury
Clients in enclosed-space fires are at high risk for inhalation injury, which can lead to airway edema and obstruction. This is the first priority.
Critical assessment finding: C. Singed nasal hairs and soot around the nares
These are hallmark signs of possible inhalation injury and may indicate airway compromise even before symptoms become severe.
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