Related Questions
Correct Answer is C
Explanation
Choice A Reason: This choice is incorrect because laboratory testing of serum potassium upon admission is an appropriate prescription for a client who has acute heart failure following MI. Serum potassium is an electrolyte that affects the cardiac function and rhythm. A normal serum potassium range is 3.5 to 5 mEq/L, and an abnormal level can indicate hypokalemia or hyperkalemia, which can cause arrhythmias, muscle weakness, or paralysis. Therefore, monitoring serum potassium is important to detect and correct any electrolyte imbalance and prevent complications.
Choice B Reason: This choice is incorrect because bumetanide 1 mg IV bolus every 12 hr is an appropriate prescription for a client who has acute heart failure following MI. Bumetanide is a loop diuretic that helps to reduce fluid retention and edema by increasing the urine output and sodium excretion. It may be used for clients who have heart failure, hypertension, or renal impairment, but it can cause hypokalemia, hypotension, or dehydration.
Therefore, administering bumetanide as prescribed can help to improve the cardiac output and reduce the preload and afterload.
Choice C Reason: This choice is correct because 0.9% normal saline IV at 50 mL/hr continuous is an inappropriate prescription for a client who has acute heart failure following MI. 0.9% normal saline is an isotonic solution that contains the same concentration of solutes as blood plasma. It may be used for clients who have fluid loss, dehydration, or shock, but it can worsen fluid overload and pulmonary edema in clients who have acute heart failure. Therefore, clarifying this prescription with the provider is necessary to prevent further deterioration of the client's condition.
Choice D Reason: This choice is incorrect because morphine sulfate 2 mg IV bolus every 2 hr PRN pain is an appropriate prescription for a client who has acute heart failure following MI. Morphine sulfate is an opioid analgesic that helps to relieve pain and anxiety by binding to the opioid receptors in the brain and spinal cord. It may be used for clients who have moderate to severe pain, dyspnea, or chest discomfort, but it can cause respiratory depression, hypotension, or nausea. Therefore, administering morphine sulfate as prescribed can help to reduce the oxygen demand and improve the cardiac function.

Correct Answer is D
Explanation
Choice A Reason: Cause of the burn is not the nurse's priority when assessing the severity of the client's burns. The cause of the burn may indicate the type and duration of exposure, such as thermal, chemical, electrical, or radiation, which can affect the depth and extent of injury. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice B Reason: Age of the client is not the nurse's priority when assessing the severity of the client's burns. The age of the client may influence the response to burn injury, such as healing time, infection risk, and fluid requirements.
However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice C Reason: Associated medical history is not the nurse's priority when assessing the severity of the client's burns. The associated medical history may affect the outcome and prognosis of burn injury, such as pre-existing conditions, medications, or allergies. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice D Reason: Location of the burn is the nurse's priority when assessing the severity of the client's burns. The location of the burn can indicate the potential for life-threatening complications, such as airway obstruction, inhalation injury, or impaired circulation. The nurse should assess for signs and symptoms of respiratory distress, such as stridor, wheezes, or cyanosis, and prepare for endotracheal intubation if needed. The nurse should also monitor for signs and symptoms of compartment syndrome, such as pain, pallor, paresthesia, pulselessness, or paralysis, and report any findings to the provider. The location of the burn can also affect the functional and cosmetic outcomes, such as vision loss, facial disfigurement, or joint contractures. The nurse should provide appropriate wound care, pain management, and rehabilitation as prescribed. Assessing for location of burn is essential to prevent further injury and preserve vital functions.
