A client with a full-thickness burn to the front of the left leg underwent skin grafting.
The nurse notes pain 6/10, dressing dry and intact, and slight edema at the graft site. Which action is the priority?

Endotracheal suctioning carries risks of hypoxia and vagal stimulation. Knowledge of respiratory physiology and emergency protocols is required to recognize when a procedure is causing clinical instability and to prioritize the immediate restoration of oxygenation and cardiac rhythm stability.

Choice A rationale

Tachycardia, arrhythmias, and desaturation during suctioning indicate acute hypoxia and myocardial stress. The nurse must stop the procedure immediately to prevent cardiac arrest and provide 100 percent oxygen to restore alveolar gas exchange and stabilize the heart rate.

Choice B rationale

Continuing the procedure while the patient is experiencing cardiac instability and severe hypoxia is dangerous. Prolonged suctioning increases the risk of further vagal stimulation and worsening hypoxemia, which could lead to fatal arrhythmias or sudden respiratory and cardiac collapse.

Choice C rationale

While the provider needs to be informed, it is not the priority. Immediate life saving intervention, such as stopping suctioning and hyper-oxygenating the client, must occur first to address the physiological distress and prevent further deterioration of the client.

Choice D rationale

Antiarrhythmics are not the first line treatment for suction induced arrhythmias. These rhythm changes are usually a direct result of hypoxia. Correcting the underlying oxygen deficiency by stopping the suction and providing supplemental oxygen usually resolves the tachycardia and irregularity..

Acute pancreatitis involves the autodigestion of the pancreas by activated enzymes. Knowledge of systemic inflammatory response and gastric acid management is necessary to understand the rationale for bowel rest and the prevention of secondary complications like stress ulcers.

Choice A rationale

Early ambulation is generally encouraged but not a priority during the acute, painful phase of pancreatitis. The client often requires bed rest to decrease metabolic demands and minimize the stimulation of pancreatic enzyme secretion and activity.

Choice B rationale

Pantoprazole is a proton pump inhibitor used to decrease gastric acid secretion. In pancreatitis, reducing acid prevents it from entering the duodenum and stimulating the release of secretin, which would otherwise trigger further pancreatic enzyme production.

Choice C rationale

Pancrelipase consists of digestive enzymes meant for chronic pancreatitis or pancreatic insufficiency. In acute pancreatitis, giving enzymes orally would further stimulate the inflamed organ and worsen the condition; the client must remain nothing by mouth.

Choice D rationale

A low-residue diet is inappropriate for acute pancreatitis. The initial treatment must be strict bowel rest (NPO) to stop all stimulus to the pancreas, allowing the inflammation to subside before reintroducing any oral intake or nutrients..