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 A
Explanation
Immediate first aid for thermal burns focuses on stopping the burning process and limiting tissue damage. This scenario requires applying knowledge of cooling mechanisms to dissipate heat from deep tissue layers without causing further vasoconstriction or injury.
Choice A rationale
Cool tap water helps dissipate heat from the skin and prevents the burn from progressing to deeper layers. Applying cool water for twenty minutes reduces edema and provides immediate pain relief without causing thermal shock.
Choice B rationale
Ice packs should never be applied directly to a burn. Extreme cold causes profound vasoconstriction, which impairs local blood flow to the injured area and can lead to frostbite or further tissue necrosis and ischemia.
Choice C rationale
While medical evaluation is necessary for serious burns, immediate cooling is the priority to stop tissue destruction. Delaying first aid to travel to a doctor without cooling the hand first allows the heat to continue.
Choice D rationale
Ointments or butter can trap heat within the skin and increase the risk of infection. Professional assessment should occur before applying topical agents, as they can interfere with the initial cleaning and debridement of the wound.
Correct Answer is A
Explanation
The nurse must apply knowledge of surgical decompression and wound care when explaining procedures to family members. Understanding how eschar restricts blood flow and how surgical incisions relieve pressure is critical for communicating the rationale behind life-saving interventions for severe burns.
Choice A rationale
An escharotomy involves making longitudinal incisions through the thick, leathery, necrotic eschar tissue. This relieves the pressure caused by edema in circumferential burns, restoring distal circulation and preventing compartment syndrome in the affected lower extremities.
Choice B rationale
Showering the client to remove dead tissue describes hydrotherapy or mechanical debridement. While this is part of routine burn care for wound cleansing, it does not address the circulatory emergency that necessitates a surgical escharotomy.
Choice C rationale
Grafting healthy skin onto a burned area is known as an autograft. This procedure is performed later in the recovery phase for wound closure and healing, not as an emergency measure to improve immediate limb circulation.
Choice D rationale
The use of specialized enzymes to remove dead tissue is enzymatic debridement. This chemical process is slower and is used to clean the wound bed, whereas an escharotomy is an immediate surgical intervention to restore perfusion..
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