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
Addressing end of life care for patients with neurodegenerative diseases requires therapeutic communication and clarification of advance directives. The nurse must apply principles of patient advocacy and ethics to ensure that specific treatment preferences are understood and documented for future implementation.
Choice A rationale
While the healthcare provider must be informed, this response shifts the responsibility away from the nurse at a critical moment of sharing. The nurse should first explore the patient preferences to provide comprehensive support and advocate for their wishes.
Choice B rationale
This open ended question facilitates an exploration of the patient values and specific desires for comfort care. It allows the nurse to document alternative interventions, such as morphine or oxygen, while respecting the patient refusal of invasive life support.
Choice C rationale
An incentive spirometer helps with lung expansion but will not prevent the ultimate neuromuscular respiratory failure associated with ALS. Giving false hope about delaying ventilation is nontherapeutic and ignores the patient expressed desire to avoid intubation entirely.
Choice D rationale
Asking why can be perceived as defensive or judgmental in therapeutic communication. It may make the patient feel they need to justify their choice, rather than allowing them to express their feelings and plan for their end of life..
Correct Answer is ["167"]
Explanation
Step 1 is 2 L × 1,000 mL = 2,000 mL.
Step 2 is 2,000 mL ÷ 12 hours = 166.666 mL/hr.
Step 3 is round 166.666 to 167 mL/hr. Final calculated answer is 167.
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