A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Insert an indwelling urinary catheter.

Inspect the mouth for signs of inhalation injuries.

Administer intravenous pain medication.

Draw blood for a complete blood cell (CBC) count.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Inserting an indwelling urinary catheter may be necessary for accurate monitoring of urine output in burn patients, but it is not the immediate priority in the emergency assessment. Urinary monitoring is important after airway and breathing have been assessed and stabilized.
B. Inspecting the mouth for signs of inhalation injury is the priority action. Burns involving the face, neck, and chest place the client at high risk for airway compromise from edema, soot, or inhaled heat and smoke. Airway management follows the “Airway, Breathing, Circulation” (ABC) approach, and early identification of inhalation injury can be life-saving.
C. Administering intravenous pain medication is important for comfort and to reduce stress response, but it does not take priority over assessing and securing the airway in a burn patient. Pain management should be initiated after life-threatening conditions are addressed.
D. Drawing blood for a CBC helps assess hemoglobin, hematocrit, and infection risk, but laboratory evaluation is not an immediate life-saving intervention. It is secondary to airway assessment and stabilization.

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Correct Answer is D

Explanation

Rationale:

A. This statement is correct. Blood volume provides the fluid needed to fill the vascular system, cardiac output determines the flow of blood, and vascular tone (the degree of constriction or dilation of blood vessels) regulates resistance. Together, these factors determine the MAP that drives blood through organs.

B. Blood volume is directly related to MAP. An increase in circulating volume, such as from fluid administration, raises venous return to the heart, increasing stroke volume and cardiac output, which subsequently increases MAP. Conversely, hypovolemia lowers MAP and reduces organ perfusion.

C. Cardiac output is the product of heart rate × stroke volume. When cardiac output increases, more blood is pumped into the arterial system per minute, raising arterial pressure and MAP. This is why interventions that improve cardiac output, such as fluids or inotropes, are used in shock to maintain MAP and perfusion.

D. This statement is incorrect. When the vascular bed dilates (vasodilation), systemic vascular resistance decreases. Because MAP is determined by MAP = CO × SVR (systemic vascular resistance), a decrease in resistance lowers MAP if cardiac output remains the same. Vasodilation can occur in conditions like septic shock, leading to hypotension despite normal or even elevated cardiac output. In contrast, vasoconstriction increases resistance and raises MAP.

A. A patient with a blunt chest trauma without difficulty breathing B. A patient with a sore neck who was immobilized in the field on a backboard with a cervical collar C. A patient with a possible fractured tibia with adequate pedal pulses D. A trauma patient with hypovolemic shock

Correct Answer is D

Explanation

Rationale:
A. A patient with blunt chest trauma who is breathing adequately is stable at the moment. While ongoing assessment is necessary, there is no immediate life-threatening compromise in airway, breathing, or circulation.

B. A patient with a sore neck who is properly immobilized has a potential cervical spine injury. The collar and backboard provide stabilization, reducing immediate risk of spinal cord injury. Although careful monitoring is required, this patient is not in immediate life-threatening danger.

C. A patient with a possible fractured tibia and adequate pedal pulses has a limb injury that, while painful, is not life-threatening. Neurovascular assessment and fracture management are important but not emergent in comparison to shock.

D. A trauma patient with hypovolemic shock is the priority because shock represents inadequate perfusion of vital organs. If untreated, hypovolemic shock can rapidly lead to organ failure and death. Immediate interventions such as fluid resuscitation and monitoring of vital signs are essential to preserve life.

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A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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