A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
Infection
Airway obstruction
Paralytic ileus
Fluid imbalance
The Correct Answer is B
Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inflammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.
Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer fluids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's fluid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous fluids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Contacting the provider for further orders is not necessary, because the client has type AB blood, which is compatible with any other blood type. The client can receive type B blood without any adverse reactions.
Choice B: Notifying the blood bank of the discrepancy is not required, because there is no discrepancy. The blood bank sent the correct type of blood for the client, according to their blood type.
Choice C: Administering the blood as ordered is the correct action, because type B blood is compatible with type AB blood. The client will not have any transfusion reactions or complications from receiving this type of blood.
Choice D: Completing an incident report is not appropriate, because there is no incident. The nurse did not make any error or mistake in administering the blood to the client. There is no need to document or report anything unusual.
Correct Answer is B
Explanation
Choice A Reason: This is incorrect because preparing for mechanical ventilation is not the priority nursing intervention, as it is an invasive and potentially harmful procedure that should be reserved for clients who have severe respiratory failure and cannot maintain adequate oxygenation with noninvasive methods.
Choice B Reason: This is correct because administering oxygen via face mask is the priority nursing intervention, as it is a noninvasive and effective way to improve oxygenation and reduce hypoxemia in a client who has low PaO2 and SaO2. Oxygen therapy can also decrease the workload of the heart and lungs and prevent further complications.
Choice C Reason: This is incorrect because preparing to administer a sedative is not the priority nursing intervention, as it may worsen the client's respiratory status and mask the signs and symptoms of hypoxemia. Sedatives should be used with caution and only after oxygenation has been optimized.
Choice D Reason: This is incorrect because assessing for indications of pulmonary embolism is not the priority nursing intervention, as it is a diagnostic rather than a therapeutic action. Pulmonary embolism is a possible cause of the client's condition, but it does not address the immediate problem of hypoxemia.
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