A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

"When the antibiotic therapy is complete."

"As soon as his albumin levels return to normal."

"Once we complete the fluid resuscitation process."

"When all of his burn wounds have closed."

Answer and Explanation

The Correct Answer is D

Choice A reason: Completion of antibiotic therapy does not necessarily correlate with a decrease in the risk of infection in burn patients. While antibiotics can help manage existing infections, the risk for new infections remains until the burn wounds are fully healed. Open burn wounds provide a portal of entry for pathogens, and the presence of necrotic tissue can further increase infection risk.

Choice B reason: Returning albumin levels to normal can improve the overall nutritional status and healing process of a burn patient, but it does not directly reduce the risk of infection. Albumin levels are more indicative of the patient's nutritional status and fluid balance. The primary concern for infection risk remains the open burn wounds, which serve as a direct route for pathogens.

Choice C reason: Completion of the fluid resuscitation process is crucial for stabilizing a burn patient's hemodynamic status and ensuring adequate perfusion to tissues. However, fluid resuscitation does not directly impact the risk of infection. The risk of infection is predominantly related to the presence and extent of open burn wounds.

Choice D reason: The correct response is that the risk for infection significantly decreases when all of the burn wounds have closed. Closed wounds provide a barrier against pathogens and reduce the risk of infection. Wound closure can be achieved through natural healing or surgical interventions such as skin grafting. Until the wounds are fully closed, the patient remains at a high risk for infection.

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Correct Answer is A

Explanation

Choice A reason: Carbon monoxide poisoning can cause the skin, particularly the face, to appear cherry-red. This occurs because carbon monoxide binds with hemoglobin in the blood, forming carboxyhemoglobin, which gives the skin this distinct color. It is a critical condition that requires immediate intervention as carbon monoxide displaces oxygen in the blood, leading to hypoxia and potentially life-threatening complications.

Choice B reason: Smoke inhalation is a common issue in burn victims and can cause respiratory distress, coughing, and airway irritation. However, it does not typically cause the face to turn a cherry-red color. The primary concerns with smoke inhalation are airway obstruction and lung damage rather than changes in skin color.

Choice C reason: Uremic poisoning, or uremia, results from severe kidney dysfunction and the accumulation of waste products in the blood. Symptoms can include fatigue, confusion, and a metallic taste in the mouth, but it does not cause a cherry-red discoloration of the face.

Choice D reason: Acute anemic hypertension is not a recognized medical condition. Anemia can cause pallor or a pale appearance of the skin, while hypertension typically does not cause skin discoloration. Therefore, this choice is not relevant to the described symptoms.

A. Increase the rate of the IV fluid administration. B. Notify the provider immediately. C. Prepare to give IV pain medication. D. Notify respiratory therapy for a breathing treatment.

Correct Answer is B

Explanation

Choice A reason: Increasing the rate of IV fluid administration is not the priority action in this situation. Although maintaining adequate fluid levels is important for patients with traumatic brain injuries, the symptoms described (pulse change, increased pulse pressure, and respiratory irregularities) indicate that the patient may be experiencing increased intracranial pressure (ICP). Fluid administration alone will not address this issue and could potentially worsen the condition if not managed carefully.

Choice B reason: The priority action is to notify the provider immediately. The changes in vital signs (decreased pulse, increased pulse pressure, and respiratory irregularities) suggest that the patient may be experiencing increased intracranial pressure (ICP), which is a medical emergency. Immediate notification of the provider is essential for timely intervention to prevent further neurological damage or complications.

Choice C reason: Preparing to give IV pain medication is not the priority in this situation. While managing pain is important, the patient's vital sign changes indicate a more serious underlying issue (potential increased intracranial pressure) that requires immediate medical attention. Pain medication alone will not address the root cause of the symptoms.

Choice D reason: Notifying respiratory therapy for a breathing treatment is not the priority action in this scenario. Although respiratory irregularities are present, the vital sign changes suggest that the patient is experiencing increased intracranial pressure. This requires immediate medical intervention by the provider to manage the underlying condition, rather than solely focusing on respiratory support.

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A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse in the emergency room is performing an assessment on a burn victim. She notes his face is a cherry-red color and suspects which of the following problems?

Correct Answer is A

Explanation

A patient has a traumatic brain injury. The nurse assesses the following: Pulse change from 82 to 60 beats/min, Pulse pressure increase from 26 to 40 mm Hg, and Respiratory irregularities. What action by the nurse takes priority?

Correct Answer is B

Explanation

The 75-year-old client is hospitalized with end-stage chronic kidney disease. Which of the following serum lab findings would the nurse expect? Select all that apply.

Nursing interventions such as taking daily weights, I&O, and monitoring specific gravity relate to which kidney function?

A 35-year-old patient arrives at the Emergency Department in acute respiratory failure. What assessment information does the nurse prioritize as needing immediate action?

A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

The healthcare provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used to assess the valves?

A patient is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? Select all that apply.