A client is in the acute phase of a burn injury. The nurse notes a Mean Arterial Pressure (MAP) of 74 mm Hg, urine output of 95 mL/hr, and a temperature of 38.6°C (101.5°F). The white blood cell (WBC) count is 18,000/mm and the burn wound has increased drainage with a foul odor.
What is the priority nursing action?
Encourage increased oral protein intake.
Administer prescribed opioid analgesic.
Reduce IV fluid infusion rate.
Notify the provider and obtain wound and blood cultures.
The Correct Answer is D
Management of burn injuries involves monitoring for systemic complications like sepsis. This scenario requires applying knowledge of systemic inflammatory response syndrome (SIRS) and infection indicators to prioritize interventions when clinical data suggest the onset of a life-threatening wound infection.
Choice A rationale
While increased protein intake is vital for wound healing during the hypermetabolic state of a burn injury, it is not the priority when a client shows active signs of systemic infection and potential sepsis requiring immediate medical intervention.
Choice B rationale
Pain management is a core component of burn care. However, the presence of fever, tachycardia, high WBC count (normal 5,000 to 10,000/mm), and foul-smelling drainage indicates a systemic infection that takes priority over routine analgesic administration for stability.
Choice C rationale
Reducing the IV fluid rate could be dangerous. In the acute phase of burns, maintaining adequate perfusion is critical. Given the signs of infection, the patient may need more fluid to support hemodynamics if they are entering septic shock.
Choice D rationale
The client exhibits classic signs of sepsis, including fever, leukocytosis, and localized wound infection symptoms. The priority is to notify the provider and obtain cultures to identify the pathogen and initiate appropriate antibiotic therapy immediately to save lives..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Administering phenytoin requires applying knowledge of intravenous drug compatibility and cardiovascular safety profiles. The nurse must prioritize monitoring for life-threatening complications associated with rapid infusion, specifically focusing on the drug's narrow therapeutic index and its significant irritant properties.
Choice A rationale
Phenytoin is highly unstable and will precipitate if mixed with dextrose solutions. It must only be diluted with 0.9 percent sodium chloride. Incorrect dilution can lead to crystalline emboli and loss of drug efficacy during administration.
Choice B rationale
Intravenous phenytoin is a known vesicant that can cause purple glove syndrome if administered into small peripheral veins like those in the hand. Use of a large-bore catheter in a large vein or central line is preferred.
Choice C rationale
Rapid infusion of phenytoin can lead to severe cardiovascular collapse, including hypotension and fatal dysrhythmias. The infusion rate should not exceed 50 mg per minute to allow the heart to tolerate the drug's membrane-stabilizing effects safely.
Choice D rationale
The standard therapeutic range for phenytoin is 10 to 20 mcg per mL, not 20 to 30 mg per mL. Levels exceeding 20 mcg per mL often result in toxicity, characterized by nystagmus, ataxia, and decreased mental status.
Correct Answer is A
Explanation
Disseminated intravascular coagulation is a complex secondary complication of sepsis. Knowledge of the coagulation cascade, specifically the paradoxical relationship between widespread microvascular clotting and systemic hemorrhage due to the depletion of clotting factors and fibrinogen, is necessary to explain this condition.
Choice A rationale
DIC begins with excessive thrombin generation, leading to widespread fibrin deposition in the microcirculation. This process consumes clotting factors and fibrinogen, eventually resulting in severe bleeding. It is a disorder characterized by abnormal, systemic activation of coagulation.
Choice B rationale
DIC is characterized by a decreased platelet count, not an elevated one. Platelets are consumed rapidly as they form numerous small clots throughout the body. Thrombocytopenia is a hallmark laboratory finding used to diagnose this life-threatening condition.
Choice C rationale
DIC is an acute, life-threatening complication, not a chronic condition requiring lifelong heparin. While heparin may be used in specific phases to stop the clotting cascade, the primary treatment focuses on resolving the underlying cause, such as sepsis.
Choice D rationale
DIC is an acquired syndrome, not a genetic disorder. While vitamin K is essential for the synthesis of certain clotting factors, the primary pathology of DIC involves the overstimulation of the clotting cascade rather than a simple deficiency.
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