A client with full-thickness and circumferential burns to the chest has been intubated and is experiencing pressure from edema that is inhibiting chest wall expansion.
Which procedure should the nurse anticipate for this client?
Chest tube insertion.
Cricothyrotomy.
Thoracentesis.
Escharotomy.
The Correct Answer is D
Circumferential burns to the chest create an inelastic band of eschar. Knowledge of respiratory mechanics and surgical emergencies is needed to identify when tissue tension prevents lung expansion, necessitating an immediate procedure to restore adequate ventilation and oxygenation.
Choice A rationale
Chest tube insertion is utilized to drain air or fluid from the pleural space. While it helps with lung expansion in a pneumothorax, it does not treat the external constriction caused by burnt, leathery tissue on the chest.
Choice B rationale
Cricothyrotomy is an emergency airway procedure used when intubation is impossible. Since the client is already intubated, the issue is not airway patency but rather the physical inability of the chest wall to expand against the eschar.
Choice C rationale
Thoracentesis is the removal of fluid from the pleural cavity via needle aspiration. This does not address the restrictive external pressure caused by circumferential, full-thickness burns that are inhibiting the mechanical rise and fall of the thorax.
Choice D rationale
An escharotomy involves making incisions through the burnt tissue to relieve pressure. This procedure allows the chest wall to expand, restoring adequate ventilation when circumferential eschar acts like a tourniquet around the patient's torso and lungs..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Postoperative monitoring requires identifying deviations from expected healing milestones. Knowledge of surgical site infections and normal physiological parameters is necessary to distinguish between typical postoperative recovery and complications like dehiscence or sepsis that require immediate medical intervention.
Choice A rationale
A respiratory rate of 18/min is within the normal adult range of 12 to 20 breaths per minute. This indicates adequate ventilation and gas exchange following abdominal surgery, suggesting no immediate respiratory distress or pulmonary complications.
Choice B rationale
Yellow-green drainage indicates purulent exudate, suggesting a surgical site infection. This is an abnormal finding 48 hours postoperatively. Normal wound healing should show serosanguinous drainage. Any sign of infection necessitates prompt notification of the healthcare provider.
Choice C rationale
Straw-colored urine is a normal finding indicating adequate hydration and renal perfusion. Standard urinary output should exceed 30 mL/hr. Clear or straw-colored urine suggests that the kidneys are filtering waste products appropriately without hematuria.
Choice D rationale
A blood pressure of 102/66 mm Hg is slightly low but often acceptable postoperatively if the client is asymptomatic. The mean arterial pressure is ≥ 65 mm Hg, which is sufficient for vital organ perfusion and tissue oxygenation.
Correct Answer is ["326.25"]
Explanation
Step 1 is 43.5 kg × 7.5 mg/kg.
Final calculated answer is 326.25
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