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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.
B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.
C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.
D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.
Correct Answer is []
Explanation
Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.
Actions to take:
- Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
- Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.
Parameters to monitor:
- Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
- Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.
Incorrect diagnoses:
The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.
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