A client is brought to the emergency department with burns over 40% of the body from apartment fire. Which assessment should take priority?

Percent of body surface burned

Respiratory status

Review of chronic illnesses

Burn depth

Answer and Explanation

The Correct Answer is B

A. Percent of body surface burned:
Important for guiding fluid resuscitation, but airway and breathing always take priority in the ABCs.

B. Respiratory status:
Inhalation injury is a life-threatening complication in fire-related burns. Assess for stridor, soot in nares/mouth, and signs of respiratory distress first.

C. Review of chronic illnesses:
Relevant for overall care planning, but not an initial priority in the emergency phase.

D. Burn depth:
Guides long-term care but is secondary to airway and breathing in the acute setting.

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Correct Answer is ["B","C","D"]

Explanation

A. Cool the burn with ice water:
Never use ice on burns. It can cause vasoconstriction and worsen tissue injury.

B. Administer opioid analgesics:
Severe pain is common in burn injuries. IV opioids are preferred for rapid onset and titration.

C. Administer systemic antibiotics:
Burn injuries compromise the skin barrier, increasing the risk of infection. Systemic antibiotics may be necessary to prevent or treat infections.

D. Keep extremities elevated:
Elevating extremities helps reduce edema and improve venous return.

E. Remove all sheets and coverings:
Sheets may provide warmth and protection. Removing them indiscriminately may worsen hypothermia or cause further trauma to the skin.

A. Apply cornstarch to keep the skin dry. B. Massage bony prominences to promote circulation. C. Reposition the client every 3 hr. D. Provide the client with a diet high in protein.

Correct Answer is D

Explanation

A. Apply cornstarch to keep the skin dry
Cornstarch can cause skin irritation and create a medium for fungal growth in moist environments.

B. Massage bony prominences to promote circulation
This may cause skin breakdown over fragile skin and bony areas, especially in older adults.

C. Reposition the client every 3 hr
Clients at risk should be repositioned at least every 2 hours to prevent pressure injury

D. Provide the client with a diet high in protein
Protein is essential for wound healing and maintaining skin integrity, especially in older adults at risk for pressure injuries.

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A client is brought to the emergency department with burns over 40% of the body from apartment fire. Which assessment should take priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

Correct Answer is D

Explanation

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