A nurse is caring for a client during the first few hours post-admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of the burn injury?

Pain

Laryngeal edema

Leukopenia

Fluid volume deficit

Answer and Explanation

The Correct Answer is C

Choice A reason: Pain is a significant concern in partial-thickness burns because the nerve endings remain intact but are exposed and irritated. Managing severe pain is a priority in the emergent phase to reduce the physiological stress response and improve the patient's comfort and cooperation with treatment.

Choice B reason: Laryngeal edema is a critical priority, especially with burns to the head and neck. Inhalation of hot gases or steam can cause rapid airway swelling and obstruction. Ensuring airway patency is the "A" in the ABCs of trauma and burn management during the emergent phase.

Choice C reason: Leukopenia, or a low white blood cell count, is not a primary concern in the first few hours (emergent phase). In fact, the initial stress response often causes a transient increase in white blood cells (leukocytosis). Infection and changes in WBC counts are typically concerns during the later acute phase.

Choice D reason: Fluid volume deficit is a major concern due to the massive shift of fluids from the intravascular to the interstitial space. Aggressive fluid resuscitation is required during the first 24 to 48 hours to prevent burn shock and maintain vital organ perfusion.

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Correct Answer is C

Explanation

Choice A reason: While a fever may be present in some cases of rhabdomyolysis due to systemic inflammation, a decrease in temperature is not the primary clinical indicator used to measure the effectiveness of the specific treatment for myoglobinuria or renal protection.

Choice B reason: Increased blood pressure might occur as a result of fluid resuscitation, but it is not the specific goal for treating rhabdomyolysis. Blood pressure is a general indicator of hemodynamic status rather than a specific measure of whether myoglobin is being cleared from the kidneys.

Choice C reason: In rhabdomyolysis, large amounts of myoglobin are released into the bloodstream, which can obstruct renal tubules and cause acute tubular necrosis. The goal of aggressive IV fluid therapy is to "flush" the kidneys. Increased urine output confirms that the myoglobin is being diluted and excreted effectively.

Choice D reason: A decreased heart rate may indicate that the patient’s fluid volume is being restored and the compensatory tachycardia is resolving. However, this is a secondary sign of hemodynamic stability and does not directly confirm the prevention of myoglobin-induced renal damage.

A. A client three hours post-myocardial infarction B. A client with trauma related blood loss C. A client with a tension pneumothorax D. A client with positive blood cultures

Correct Answer is A

Explanation

Choice A reason: Cardiogenic shock occurs when the heart’s muscular wall fails to pump effectively. A myocardial infarction (MI) causes necrosis of the cardiac tissue; if more than 40% of the left ventricle is damaged, the heart cannot maintain adequate cardiac output, leading directly to cardiogenic shock.

Choice B reason: A client with trauma-related blood loss is at risk for hypovolemic shock. This type of shock is caused by a lack of intravascular volume rather than a primary failure of the heart muscle itself, distinguishing it from the pump-failure mechanism of cardiogenic shock.

Choice C reason: A tension pneumothorax causes obstructive shock. The high pressure in the thoracic cavity shifts the mediastinum and compresses the great vessels (superior and inferior vena cava), physically preventing blood from returning to the heart, which is different from a primary muscular failure.

Choice D reason: A client with positive blood cultures is at risk for septic shock. This is a form of distributive shock caused by systemic vasodilation and increased capillary permeability in response to an overwhelming infection, rather than an initial failure of the cardiac pump.

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A nurse is caring for a client during the first few hours post-admission to the burn unit with partial-thickness burns of the trunk and head. Which potential problem is the least concern for the nurse during the emergent phase of the burn injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client diagnosed with rhabdomyolysis with an elevated myoglobin treated with intravenous fluid. Which finding by the nurse indicates the intervention was effective?

Correct Answer is C

Explanation

Which client is at the greatest risk of developing cardiogenic shock?

Correct Answer is A

Explanation

The nurse is caring for a client with suspected sepsis. What actions will the nurse take within one hour of the client being identified as being at risk for sepsis? (Select all that apply)

The nurse is caring for a client with septic shock and assesses blood oozing out from the peripheral intravenous site, bleeding gums, and blood in the indwelling urinary catheter bag. Which intervention would the nurse implement first?

A client in hypovolemic shock is receiving rapid infusions of crystalloid fluids. Which assessment finding requires immediate nursing action?

A nurse has educated a client on an epinephrine autoinjector. What statement by the client indicates additional instruction is needed?

Which client does the nurse assess most carefully for obstructive shock?

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A nurse is caring for a client with disseminated intravascular coagulation (DIC). Which medication would the nurse anticipate administering?

A client suffered a 45 percent total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds are absent in all four abdominal quadrants. Which is the nurse's best action?