A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

Maintain adequate IV hydration

Administer broad-spectrum antibiotics

Give IV potassium chloride

Prepare intramuscular pain medications

Answer and Explanation

The Correct Answer is A

A. Maintain adequate IV hydration: The first priority in major burns is fluid resuscitation due to massive fluid shifts and risk of hypovolemic shock.

B. Administer broad-spectrum antibiotics: Not a priority during the initial resuscitative phase. Infection control comes later unless signs of sepsis appear.

C. Give IV potassium chloride: Burn patients often experience hyperkalemia initially due to cell lysis; potassium is not given early.

D. Prepare intramuscular pain medications: IM route is avoided due to poor perfusion and risk of inadequate absorption in burn patients.

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Correct Answer is C

Explanation

A. Obtain a complete blood count (CBC): This is not the immediate action in an active bleeding scenario.

B. Start IV fluids: This may be needed later if significant blood loss occurs, but not the first response.

C. Apply direct pressure: Bleeding from a fistula requires immediate direct pressure to prevent blood loss and preserve vascular access.

D. Administer pain medication: Pain management is important but not the priority in acute bleeding.

A. Orange juice B. Bananas C. Grapefruit juice D. Smoked salmon

Correct Answer is C

Explanation

A. Orange juice: Does not affect cyclosporine metabolism.

B. Bananas: No known interaction with cyclosporine.

C. Grapefruit juice: Inhibits CYP3A4 enzyme in the liver, which increases cyclosporine levels, leading to toxicity.

D. Smoked salmon: May contain sodium but does not interact with cyclosporine metabolism.

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A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

Correct Answer is C

Explanation

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

Correct Answer is C

Explanation

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