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 ["2300"]
Explanation
Step 1 is (25,000 units ÷ 250 mL) × 23 mL = 2,300 units per hour.
Final calculated answer is 2,300.
Correct Answer is B
Explanation
Management of esophageal varices requires reducing the pressure gradient within the portal venous system. This scenario necessitates applying knowledge of splanchnic vasoconstriction and hemodynamic stability to prevent life-threatening hemorrhage and manage portal hypertension through pharmacological intervention and nursing surveillance.
Choice A rationale
Lactulose is a synthetic disaccharide that lowers blood ammonia levels by acidifying colonic contents and promoting excretion. While used in hepatic encephalopathy, it does not directly reduce portal hypertension or stop acute variceal bleeding.
Choice B rationale
Propranolol is a nonselective beta-blocker that reduces portal pressure by decreasing cardiac output and causing splanchnic vasoconstriction. It is the gold standard for preventing further variceal bleeding by lowering the hepatic venous pressure gradient.
Choice C rationale
Omeprazole is a proton pump inhibitor that reduces gastric acid secretion by inhibiting the hydrogen-potassium ATPase pump. While it prevents stress ulcers and treats gastritis, it has no direct hemodynamic effect on portal venous pressure.
Choice D rationale
Furosemide is a loop diuretic that inhibits sodium and chloride reabsorption in the loop of Henle. It is used to manage ascites or edema but does not effectively target the portal hypertension causing varices.
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