A nurse is assessing multiple burn patients after a chemical accident. Which patient should the nurse see first based on the severity and potential complications of their burn?

A patient with full-thickness burns covering 3% of TBSA on the hand, caused by a chemical splash.

A patient with second-degree burns covering 15% of total body surface area (TBSA) from chemical exposure to their back.

A patient presenting with chemical burns around the face and neck area, with signs of difficulty breathing.

A patient with minor superficial burns on the arms after a chemical spill that resulted in redness and some pain.

Answer and Explanation

The Correct Answer is C

Chemical burns require rapid assessment and prioritization based on airway involvement, burn depth, and total body surface area affected. Burns involving the face and neck are particularly dangerous because they can quickly lead to airway edema, inhalation injury, and respiratory compromise. In emergency triage, airway, breathing, and circulation (ABCs) take precedence over burn size or depth alone. Any indication of respiratory distress in a burn patient represents an immediate life-threatening emergency.

Rationale:
A. A patient with full-thickness burns covering 3% TBSA on the hand is serious but not immediately life-threatening. While full-thickness burns require surgical management and infection prevention, a small localized area does not typically compromise airway, breathing, or circulation. This patient should be treated promptly but not before those with airway involvement.

B. A patient with second-degree burns covering 15% TBSA on the back requires significant fluid management and wound care, but there is no indication of airway compromise. Although the burn size is clinically important and may require fluid resuscitation, it does not pose an immediate threat to life compared to airway obstruction risks.

C. A patient with chemical burns to the face and neck with difficulty breathing is the priority because airway compromise is imminent. Chemical exposure in this region can cause rapid swelling, airway edema, and inhalation injury leading to obstruction. Immediate assessment and intervention, including airway protection, are critical to prevent respiratory failure and death.

D. A patient with minor superficial burns on the arms presents the least urgency. These burns involve only the epidermis and typically result in redness and pain without systemic or airway complications. This patient can be safely managed after higher-acuity burn cases have been stabilized.

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Correct Answer is C

Explanation

Autonomic dysreflexia is a life-threatening condition that occurs in clients with spinal cord injuries at or above T6 due to an exaggerated autonomic response to a noxious stimulus below the level of injury. It is commonly triggered by bladder distention, bowel impaction, or other irritants. This leads to sudden hypertension, pounding headache, bradycardia, and diaphoresis above the level of injury. Immediate identification and removal of the triggering stimulus is the priority to prevent complications such as stroke or seizures.

Rationale:
A. Administering an antihypertensive medication is not the first action because the priority is to identify and eliminate the underlying cause of the autonomic dysreflexia. While medications may be needed if symptoms persist, treating the trigger (often bladder or bowel-related) is the most immediate and effective intervention. Giving medication without removing the stimulus does not resolve the root cause of the crisis.

B. Placing the client in a supine position is incorrect because it can worsen hypertension by increasing venous return and intracranial pressure. The recommended position is to elevate the head of the bed to reduce blood pressure and promote orthostatic pooling of blood in the lower extremities. Positioning alone, however, is not sufficient without addressing the triggering stimulus.

C. Checking the urinary catheter for kinks is the priority action because bladder distention is the most common cause of autonomic dysreflexia. An obstructed catheter can lead to rapid bladder filling, triggering the autonomic response. Immediate assessment and relief of urinary retention help reduce blood pressure and resolve symptoms quickly.

D. Performing digital rectal stimulation is contraindicated as an initial intervention because it may worsen the episode if a bowel impaction is present and has not been properly prepared for disimpaction. Additionally, rectal stimulation can further increase autonomic stimulation and elevate blood pressure. It should only be done after stabilizing the client and addressing more urgent causes such as bladder obstruction.

A. Stable respiratory rate per minute as prescribed B. Cuff pressure maintained above 30 cm H20 C. Excess secretions in the airway D. Client experiencing bronchospasm E. Client biting the endotracheal tubing

Correct Answer is ["C","D","E"]

Explanation

Mechanical ventilation alarms are critical safety features that alert the nurse to changes in airway resistance or lung compliance. A high-pressure alarm indicates increased resistance to airflow, which can be caused by airway obstruction, bronchospasm, secretions, or patient-related factors such as biting the endotracheal tube. Prompt identification of the cause is essential to restore adequate ventilation and prevent hypoxia or barotrauma.

Rationale:
A. Stable respiratory rate per minute as prescribed does not contribute to a high-pressure alarm. A set and stable respiratory rate indicates that the ventilator is functioning as intended and does not reflect increased airway resistance or obstruction. This finding is unrelated to causes of increased airway pressure.

B. Cuff pressure maintained above 30 cm H₂O is not a direct cause of a high-pressure ventilator alarm, although it may increase the risk of tracheal mucosal injury. High-pressure alarms are typically triggered by airway obstruction or reduced lung compliance rather than cuff inflation levels. Normal cuff pressures are maintained to prevent air leaks and aspiration.

C. Excess secretions in the airway can obstruct airflow through the endotracheal tube, increasing resistance and triggering a high-pressure alarm. Secretions narrow the airway lumen, making ventilation more difficult and requiring suctioning to restore patency. This is a common and reversible cause of ventilator alarms.

D. Bronchospasm increases airway resistance due to constriction of bronchial smooth muscles, which reduces airflow and elevates airway pressures. This condition is commonly seen in clients with asthma or reactive airway disease. It requires prompt intervention with bronchodilators to relieve airway obstruction.

E. Biting the endotracheal tube can physically obstruct airflow, leading to increased resistance and activation of the high-pressure alarm. This is often seen in inadequately sedated clients or those emerging from sedation. Use of bite blocks or sedation adjustment may be necessary to prevent recurrence.

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A nurse is assessing multiple burn patients after a chemical accident. Which patient should the nurse see first based on the severity and potential complications of their burn?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a C4 spinal cord injury with an indwelling urinary catheter who exhibits signs of autonomic dysreflexia, including a severe headache and hypertension. What should the nurse do first?

Correct Answer is C

Explanation

Which of the following factors could contribute to a high pressure alarm on a mechanical ventilator? Select All that Apply.

Correct Answer is ["C","D","E"]

Explanation

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