A nurse is assessing a client with a major burn injury.
Which of the following findings should the nurse prioritize?
The client is producing black colored sputum.
The client has large blistered areas over his chest.
The client has edema at the burn site.
The client has decreased sensation over the burn areas.
The Correct Answer is A
Choice A rationale
The production of black colored sputum in a client with a major burn injury could indicate inhalation injury, which is a serious complication associated with burns. Inhalation injury can lead to respiratory failure, a leading cause of death in patients with burn injuries.
Choice B rationale
While large blistered areas over the chest indicate a significant burn injury, they are not immediately life-threatening. These areas will require wound care and monitoring for infection.
Choice C rationale
Edema at the burn site is a common response to burn injuries. It is caused by an increase in capillary permeability following the injury. While it needs to be monitored, it is not the highest priority.
Choice D rationale
Decreased sensation over the burn areas could indicate a deep partial-thickness or full-thickness burn. While this is a serious condition that will require treatment, it is not as immediately life-threatening as an inhalation injury.
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Related Questions
Correct Answer is A
Explanation
Choice A rationale
During the fluid resuscitation phase of burn management, the primary goal is to restore circulating volume and preserve vital organ and tissue perfusion. One of the most effective methods for assessing the results of fluid resuscitation is monitoring urine output. A urine output greater than 0.5 mL/kg/hr is generally considered an indicator of adequate fluid resuscitation.
Choice B rationale
While clear bilateral breath sounds are an important part of overall patient assessment, they are not the best method for assessing the results of fluid resuscitation in burn management.
Choice C rationale
Serum hemoglobin is not the best indicator for assessing the results of fluid resuscitation in burn management. While it can provide information about the patient’s overall health and blood volume, it does not directly reflect the adequacy of fluid resuscitation.
Choice D rationale
A heart rate of 122/min could indicate a response to pain, anxiety, or inadequate fluid resuscitation. However, it is not the best method for assessing the results of fluid resuscitation in burn management.
Correct Answer is B
Explanation
Choice A rationale
Pressing down on the orbital area of the eye is not typically used as it can cause injury to the eye.
Choice B rationale
Pinching the trapezius muscle is a common method used to elicit a response from a painful stimulus in an unresponsive patient. It is considered safe and effective.
Choice C rationale
Using a 25 gauge needle to elicit a response is not typically recommended as it can cause unnecessary harm to the patient.
Choice D rationale
Eliciting a reflex with a reflex hammer is not typically used to assess responsiveness to painful stimuli. Reflex hammers are primarily used to test reflexes, not responsiveness.
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