A nurse is assessing a client with a major burn injury.

Which of the following findings should the nurse prioritize?

Choice A rationale
While emptying the gas from the pouch like you would if the pouch was full of stool might seem like a logical solution, it is not the most appropriate response. This could potentially lead to messiness and odor, which could cause embarrassment and discomfort for the patient.
Choice B rationale
Peeling back a tiny corner of the skin barrier to allow gas to escape is the most appropriate response. This allows the gas to be released in a controlled manner, reducing the risk of the pouch becoming too full and uncomfortable for the patient. It also minimizes the risk of odor and messiness.
Choice C rationale
Making a tiny pinhole in the top of the pouch to let air out is not recommended. This could potentially lead to leakage of stool, causing messiness and odor. It could also damage the pouch, requiring it to be replaced more frequently.
Choice D rationale
Removing the pouch and putting on a new one when it gets too full of gas is not the most appropriate response. This could be inconvenient for the patient and could potentially lead to skin irritation from frequent changes. It also does not address the issue of the pouch filling with gas.

Choice A rationale
Gastroesophageal reflux disease (GERD) is a chronic condition where stomach acid frequently flows back into the esophagus, irritating the lining and causing symptoms like heartburn. Protonix (pantoprazole) is a proton pump inhibitor that decreases the amount of acid produced in the stomach. While it is used to treat GERD, it is not typically used prophylactically in trauma patients.
Choice B rationale
Stress ulcers are a type of peptic ulcer that is particularly common in critically ill or severely stressed patients, such as those with severe trauma like an automobile accident. These ulcers occur when the body’s physical stress leads to increased gastric acid secretion, which can damage the gastric mucosa and lead to ulcers. Protonix, by reducing stomach acid, can help prevent these ulcers in high-risk patients. This is why it is often administered prophylactically in severe trauma cases.
Choice C rationale
Dumping syndrome is a condition that can occur after surgery to remove all or part of your stomach or after surgery to bypass your stomach to help you lose weight. It’s also known as rapid gastric emptying. Protonix is not typically used to prevent dumping syndrome.
Choice D rationale
Gastritis is an inflammation of the stomach lining. While Protonix can be used to treat gastritis, it is not typically used prophylactically for this condition in trauma patients.