A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

Maintain adequate IV hydration

Administer broad-spectrum antibiotics

Give IV potassium chloride

Prepare intramuscular pain medications

Answer and Explanation

The Correct Answer is A

A. Maintain adequate IV hydration: The first priority in major burns is fluid resuscitation due to massive fluid shifts and risk of hypovolemic shock.

B. Administer broad-spectrum antibiotics: Not a priority during the initial resuscitative phase. Infection control comes later unless signs of sepsis appear.

C. Give IV potassium chloride: Burn patients often experience hyperkalemia initially due to cell lysis; potassium is not given early.

D. Prepare intramuscular pain medications: IM route is avoided due to poor perfusion and risk of inadequate absorption in burn patients.

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Correct Answer is B

Explanation

A. Place the drainage bag above the level of the client's abdomen: This would impede drainage by gravity. The drainage bag should be below abdominal level to promote outflow.

B. Warm the dialysate solution prior to instillation: Warming the solution enhances diffusion, promotes comfort, and prevents abdominal cramping. Use a warming pad, not a microwave.

C. Monitor vital signs every 2 hours during the procedure: While vital signs are monitored, more frequent monitoring is often required during the initial phase or if the patient is unstable.

D. Maintain the client in a left lateral position during dialysis: The semi-Fowler’s position is preferred to facilitate flow and lung expansion, not lateral positioning.

A. Administering sodium polystyrene sulfonate. B. Initiating an IV potassium infusion. C. Administering a potassium-sparing diuretic. D. Encouraging the client to eat bananas.

Correct Answer is A

Explanation

A. Administering sodium polystyrene sulfonate:
This medication removes potassium through the GI tract and is used to treat hyperkalemia.

B. Initiating an IV potassium infusion:
The client already has hyperkalemia; giving potassium would worsen it.

C. Administering a potassium-sparing diuretic:
These medications retain potassium and would further elevate potassium levels.

D. Encouraging the client to eat bananas:
Bananas are high in potassium and should be avoided in hyperkalemia.

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A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse Implement to ensure proper dialysate exchange?

Correct Answer is B

Explanation

A nurse is reviewing laboratory values of a client with chronic renal failure and discovers the client has a serum potassium of 6.2 mEq/L. Which of the following interventions should the nurse anticipate?

Correct Answer is A

Explanation

A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

A nurse is caring for a client who is prescribed cyclosporine following a kidney transplant. The nurse should instruct the client that which of the following foods can increase cyclosporine levels to a toxic level?

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?