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Reason: Preventing musculoskeletal disability is important, but not the priority focus of care. The nurse should first assess and manage the client's life-threatening injuries, such as airway obstruction, bleeding, shock, or brain injury.

Reason: Stabilizing cardiac arrhythmias is also important, but not the priority focus of care. The nurse should monitor the client's cardiac rhythm and treat any arrhythmias that may occur, but only after securing the airway and breathing.

Reason: Decreasing intracranial pressure is another important goal, but not the priority focus of care. The nurse should assess the client's neurological status and intervene to prevent or reduce increased intracranial pressure, such as elevating the head of the bed, maintaining normothermia, and administering osmotic diuretics. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Equal amount of fluid drainage in each collection chamber is not a sign of proper chest tube function. The amount of fluid drainage depends on the type and extent of the client's injury or surgery, and may vary from one chamber to another.

Reason: Continuous bubbling within the water seal chamber is not a sign of proper chest tube function. It indicates that there is an air leak in the system, either from the client's pleural space or from a loose connection. The nurse should locate and correct the source of the leak.

Reason: Absence of fluid in the drainage tubing is not a sign of proper chest tube function. It may indicate that the chest tube is obstructed, kinked, or clamped, or that the suction is not working properly. The nurse should assess and troubleshoot the chest tube system.

Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer fluids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's fluid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous fluids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Reason: Observing for cerebrospinal fluid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Checking the oximeter is also important, but not the first action that the nurse should take. The oximeter measures the oxygen saturation of the blood, which reflects the adequacy of gas exchange in the lungs. The nurse should maintain the oxygen saturation above 90%, and administer supplemental oxygen as prescribed.
However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inflammation, or damage to the hypothalamus, which can affect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Observing for cerebrospinal fluid (CSF) leaks from the evacuation site is important, but not the first action that the nurse should take. CSF leaks can indicate a breach in the dura mater, which can increase the risk of infection and meningitis. The nurse should inspect the dressing and the nose and ears for any clear or bloody drainage, and report any findings to the provider. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Checking the oximeter is also important, but not the first action that the nurse should take. The oximeter measures the oxygen saturation of the blood, which reflects the adequacy of gas exchange in the lungs. The nurse should maintain the oxygen saturation above 90%, and administer supplemental oxygen as prescribed.
However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Assessing for an increase in temperature is another important action, but not the first one that the nurse should take. An increase in temperature can indicate an infection, inflammation, or damage to the hypothalamus, which can affect the thermoregulation of the body. The nurse should monitor the temperature and administer antipyretics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and perfusion.

Reason: Urine output is not a finding that should decrease with adequate fluid replacement. On the contrary, urine output should increase as the fluid therapy restores the renal perfusion and function. The nurse should monitor the urine output and ensure that it is at least 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.

Reason: Weight is not a finding that should decrease with adequate fluid replacement. On the contrary, weight may increase as the fluid therapy restores the hydration status and corrects the fluid deficit. The nurse should monitor the weight and compare it with the pre-burn weight to evaluate the fluid balance.

Reason: Blood pressure is not a finding that should decrease with adequate fluid replacement. On the contrary, blood pressure may increase as the fluid therapy restores the vascular tone and improves the tissue perfusion. The nurse should monitor the blood pressure and expect it to increase as the fluid therapy compensates for the fluid loss.

Reason: Dextran 70 is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Dextran 70 is a plasma expander that increases the blood volume and viscosity, which can worsen the intracranial pressure by increasing the cerebral blood flow and edema.

Reason: Hydroxyethyl starch is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Hydroxyethyl starch is another plasma expander that has similar effects as dextran 70, and can also increase the risk of coagulopathy and renal failure.

Reason: Albumin 25% is not a medication that the nurse should plan to administer for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Albumin 25% is a colloid solution that increases the oncotic pressure and draws fluid from the interstitial space into the intravascular space, which can also worsen the intracranial pressure by increasing the cerebral blood flow and edema.

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.

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.

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.

Reason: Albumin 25% is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Albumin 25% is a colloid solution that increases the oncotic pressure and draws fluid from the interstitial space into the intravascular space, which can worsen the intracranial pressure by increasing the cerebral blood flow and edema.

Reason: Dextran 70 is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Dextran 70 is a plasma expander that increases the blood volume and viscosity, which can also worsen the intracranial pressure by increasing the cerebral blood flow and edema.

Reason: Hydroxyethyl starch is not a medication that the nurse should plan to administer for a client who is experiencing Cushing's triad following a subdural hematoma. Hydroxyethyl starch is another plasma expander that has similar effects as dextran 70, and can also increase the risk of coagulopathy and renal failure.