The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area.
The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?
The client's pulse oximeter reading is 95 percent.
The client's urinary output is 50 mL in two hours.
The client reports a pain level of 9 out of 10.
The client has localized edema around the burn site.
The Correct Answer is B
This scenario requires applying knowledge of burn pathophysiology, fluid resuscitation, and emergency prioritization. Assessing deep tissue damage involves monitoring for systemic complications such as hypovolemia or airway compromise. Critical thinking is needed to distinguish between expected post-burn symptoms and life-threatening physiological shifts.
Choice A rationale
A saturation of 95 percent is within the acceptable normal range of 95 to 100 percent. While chest burns can impact ventilation, this specific value indicates adequate oxygenation and is not currently a priority over circulatory concerns.
Choice B rationale
Normal urinary output is ≥ 0.5 mL/kg/hr or roughly 30 mL/hr. An output of 25 mL/hr indicates poor renal perfusion or hypovolemia. This suggests inadequate fluid resuscitation, which is a life-threatening complication in major burn injuries.
Choice C rationale
Pain is expected with partial-thickness burns due to exposed nerve endings. While severe pain requires intervention, it is considered a psychosocial or non-life-threatening priority compared to hemodynamic instability or organ failure signaled by low urine output.
Choice D rationale
Localized edema is a standard inflammatory response in burn victims caused by increased capillary permeability. It is an expected finding within the first 24 to 48 hours and does not indicate an immediate systemic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Postoperative care for cardiac surgery requires balancing pain management with respiratory function. Knowledge of pulmonary mechanics and the risks of atelectasis is necessary to identify how analgesia facilitates deep breathing and coughing to prevent pneumonia and improve oxygenation.
Choice A rationale
Opioids can cause vasodilation and subsequent hypotension, but reducing blood pressure is not the therapeutic goal of analgesia in this context. While beneficial for cardiac workload, it is not the most critical recovery factor here.
Choice B rationale
Anxiety reduction is a secondary benefit of pain control that improves patient comfort. However, physiological stabilization and the prevention of respiratory complications take precedence over psychological comfort in the immediate postoperative phase after a bypass.
Choice C rationale
Postoperative pain causes guarded, shallow respirations, increasing the risk of lung collapse. Effective analgesia allows the client to perform deep breathing and incentive spirometry, which are vital for maintaining alveolar expansion and preventing secondary infections.
Choice D rationale
Sleep is necessary for cellular repair and overall recovery. While opioids help a patient rest, the primary physiological priority for a bypass patient is maintaining adequate gas exchange through effective ventilation, which requires active respiratory effort.
Correct Answer is B
Explanation
Postoperative monitoring requires identifying deviations from expected healing milestones. Knowledge of surgical site infections and normal physiological parameters is necessary to distinguish between typical postoperative recovery and complications like dehiscence or sepsis that require immediate medical intervention.
Choice A rationale
A respiratory rate of 18/min is within the normal adult range of 12 to 20 breaths per minute. This indicates adequate ventilation and gas exchange following abdominal surgery, suggesting no immediate respiratory distress or pulmonary complications.
Choice B rationale
Yellow-green drainage indicates purulent exudate, suggesting a surgical site infection. This is an abnormal finding 48 hours postoperatively. Normal wound healing should show serosanguinous drainage. Any sign of infection necessitates prompt notification of the healthcare provider.
Choice C rationale
Straw-colored urine is a normal finding indicating adequate hydration and renal perfusion. Standard urinary output should exceed 30 mL/hr. Clear or straw-colored urine suggests that the kidneys are filtering waste products appropriately without hematuria.
Choice D rationale
A blood pressure of 102/66 mm Hg is slightly low but often acceptable postoperatively if the client is asymptomatic. The mean arterial pressure is ≥ 65 mm Hg, which is sufficient for vital organ perfusion and tissue oxygenation.
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