The client is admitted to the emergency department with a full-thickness burn over the front of both legs.
Which priority intervention should the nurse implement?
Maintain a sterile environment when caring for the client.
Assess the client's pain level on a 1 to 10 pain scale.
Administer intravenous antibiotic therapy.
Prepare to administer a large volume of Lactated Ringer's solution.
The Correct Answer is D
Full thickness burns trigger massive systemic inflammatory responses and capillary leak syndrome. The clinical priority is addressing hypovolemic shock through aggressive fluid resuscitation to maintain organ perfusion, particularly when large surface areas like both legs are involved.
Choice A rationale
Sterile environments prevent secondary infections and sepsis in denuded skin areas. While infection control is vital in burn management, it is a secondary goal compared to the immediate physiological threat of hypovolemic shock and cardiovascular collapse.
Choice B rationale
Pain assessment is standard nursing practice, yet full thickness burns often destroy nerve endings, potentially resulting in less pain than partial thickness burns. Regardless, physiological stabilization and fluid replacement take precedence over subjective pain scaling in emergencies.
Choice C rationale
Prophylactic antibiotics are not typically the initial priority in acute burn care. Fluid resuscitation and airway management are paramount. Systemic antibiotics are usually reserved for documented infections rather than immediate emergency department stabilization of fluid status.
Choice D rationale
Burn injuries cause significant fluid shifts from the intravascular to the interstitial space. Administering Lactated Ringer solution is the gold standard for restoring volume and preventing acute tubular necrosis or organ failure during the first 24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Managing increased intracranial pressure requires applying knowledge of osmotic therapy, cerebral perfusion, and neurological positioning. Nurses must prioritize interventions that rapidly reduce cerebral edema while maintaining physiological stability and preventing herniation in patients with traumatic brain injuries or intracranial hypertension.
Choice A rationale
Pentobarbital is a barbiturate used for medically induced comas to reduce cerebral metabolic demand. While effective for refractory intracranial hypertension, it is typically a secondary or tertiary intervention rather than the immediate priority for an upward trend in pressure.
Choice B rationale
Mannitol is an osmotic diuretic that creates an osmotic gradient, pulling fluid from the cerebral interstitial space into the vascular compartment. This rapidly reduces brain volume and intracranial pressure, making it the first-line pharmacological priority for acute elevations.
Choice C rationale
Hyperventilation decreases PaCO2, causing cerebral vasoconstriction and reduced blood volume. However, excessive hyperventilation can cause cerebral ischemia. Increasing the rate to 20 should only be done under specific medical direction and is not the primary nursing priority here.
Choice D rationale
Proper positioning, such as head of bed elevation and avoiding neck flexion, facilitates venous drainage from the brain. While important, it is a supportive measure and less effective than osmotic diuretics for treating an acute, upward trend.
Correct Answer is C
Explanation
Management of hypertensive crisis involves using calcium channel blockers to achieve rapid vascular relaxation. Knowledge of pharmacodynamics is necessary to explain how nicardipine reduces systemic vascular resistance to mitigate the risk of cerebrovascular accidents and end organ damage in emergencies.
Choice A rationale
Nicardipine is a dihydropyridine calcium channel blocker that primarily causes vasodilation. It does not act as a positive chronotrope. Increasing heart rate in a hypertensive crisis could dangerously increase myocardial oxygen demand and exacerbate the clinical situation.
Choice B rationale
The medication does not possess analgesic properties or stimulate endorphin release. While the headache may improve as intracranial pressure decreases from lowered blood pressure, the primary pharmacological mechanism is vascular smooth muscle relaxation rather than pain modulation.
Choice C rationale
Nicardipine inhibits calcium ion influx into vascular smooth muscle, leading to rapid peripheral vasodilation. In a hypertensive emergency (BP > 180/120 mm Hg), quick reduction is critical to prevent intracranial hemorrhage, encephalopathy, or ischemic stroke.
Choice D rationale
Nicardipine does not function as a diuretic. While lowering blood pressure reduces renal strain, it does not promote fluid loss through the kidneys. Diuretics like furosemide are separate agents used for volume related hypertension or edema.
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