The practical nurse (PN) receives a report of a stable client who experienced partial-thickness burns over 30% of the body surface area (BSA) 3 days ago.
Which complication is most important for the PN to anticipate?
Elevated blood pressure.
Curling's ulcer.
Compartment syndrome.
Excruciating pain.
The Correct Answer is B
The correct answer is choice b. “Curling’s ulcer.”
Choice A rationale:
Elevated blood pressure is not a common complication specifically associated with partial-thickness burns. It may occur due to pain or stress but is not the most critical complication to anticipate.
Choice B rationale:
Curling’s ulcer, a type of stress ulcer, is a significant complication that can develop in burn patients due to the stress response and reduced blood flow to the gastrointestinal tract.
Choice C rationale:
Compartment syndrome is more commonly associated with circumferential full-thickness burns rather than partial-thickness burns.
Choice D rationale:
Excruciating pain is a symptom rather than a complication. While pain management is crucial, it is not the most critical complication to anticipate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Protamine sulfate is an antidote for heparin overdose and should be administered slowly intravenously to avoid rapid hemodynamic changes and potential adverse reactions.Administering it within 30 minutes ensures timely reversal of heparin’s anticoagulant effects.
Choice B rationale:
Administering protamine sulfate rapidly intramuscularly is incorrect because intramuscular administration is not recommended due to the risk of hematoma formation and slower absorption compared to intravenous administration.
Choice C rationale:
While slow intravenous administration is correct, the timing of 60 minutes is less effective compared to 30 minutes for reversing heparin’s effects promptly.
Choice D rationale:
Rapid intramuscular administration is incorrect for the same reasons as Choice B.Rapid administration can cause adverse reactions, and intramuscular administration is not the preferred route.
Correct Answer is D
Explanation
Choice A rationale:
Continue with the blood pressure assessment. Continuing with the blood pressure assessment without addressing the observed auscultatory gap could lead to an inaccurate reading. It's important to investigate and note the presence of an auscultatory gap before proceeding with the assessment.
Choice B rationale:
Reposition the stethoscope over the brachial artery. Repositioning the stethoscope may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
Choice C rationale:
Reinflate the cuff to a higher number. Reinflating the cuff to a higher number without addressing the auscultatory gap can result in an inaccurate reading. The presence of an auscultatory gap should be noted and managed appropriately.
Choice D rationale:
Note the presence of an auscultatory gap. This is the correct choice. An auscultatory gap is a temporary disappearance of sounds during the blood pressure measurement, and it may indicate underlying cardiovascular issues. The nurse should note its presence, document it, and take appropriate action if necessary.
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