A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?
Assessing psychosocial coping
Adequate fluid resuscitation
Provide nutritional support
Mitigating risk of infection
The Correct Answer is B
A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.
B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.
C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.
D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Client with partial and deep partial thickness burns on the face and neck with high-pitched respiratory sounds: High-pitched respiratory sounds (stridor) suggest impending airway obstruction, which is life-threatening and requires immediate intervention.
B. Client with facial burns and expectorating sooty secretions in no distress: At risk for inhalation injury but not in immediate respiratory distress.
C. Client with dry, black skin on both hands and a history of diabetes mellitus: Eschar and possible full-thickness burns are serious but not immediately life-threatening compared to airway compromise.
D. Client with moist blisters over the back and who reports pain as 10: Pain is expected and manageable; airway takes priority.
Correct Answer is B
Explanation
A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.
B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.
C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.
D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.
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