A nurse is caring for a client who has sustained a gasoline burn to 25% of the body. Which of the following is a priority safety concern when caring for this client?
Elevation of the head of the bed by 30 degrees
Determining the amount of gasoline that the client encountered
Asking the client when they last ate a meal
Decontamination of the client
The Correct Answer is D
A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.
B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.
C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.
D. Decontamination of the client
When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Metabolic acidosis:
Metabolic acidosis is characterized by a low pH (<7.35) and a low bicarbonate level (<22 mEq/L) due to an excess of acids in the body or a loss of bicarbonate. However, in the given ABG values, the pH is low (7.22), but the bicarbonate level is elevated (28 mEq/L), which does not align with metabolic acidosis. Therefore, metabolic acidosis is not the correct interpretation in this case.
B. Respiratory acidosis:
Respiratory acidosis occurs when there is inadequate removal of carbon dioxide (CO2) by the lungs, leading to an accumulation of CO2 in the blood and a decrease in pH. In the ABG values provided, the pH is low (7.22), and the PaCO2 is elevated (68 mm Hg), indicating respiratory acidosis as the primary disturbance. This interpretation is supported by the elevated PaCO2 and the low pH, making it the correct choice based on the given data.
C. Respiratory alkalosis:
Respiratory alkalosis results from hyperventilation, leading to excessive elimination of CO2 and a decrease in PaCO2 levels. However, in the ABG values presented, the PaCO2 is elevated (68 mm Hg), which contradicts the expected decrease seen in respiratory alkalosis. Therefore, respiratory alkalosis is not the correct interpretation of the ABG values in this case.
D. Metabolic alkalosis:
Metabolic alkalosis is characterized by a high pH (>7.45) and a high bicarbonate level (>26 mEq/L) due to excessive loss of acids or an increase in bicarbonate levels. However, in the ABG values provided, the pH is low (7.22), and the bicarbonate level is elevated (28 mEq/L), which is not consistent with metabolic alkalosis. Therefore, metabolic alkalosis is not the correct interpretation based on the given data.
Correct Answer is A
Explanation
A. Urine output is greater than 0.5 mL/kg/hr
During the fluid resuscitation phase of burn management, one of the primary goals is to maintain adequate tissue perfusion and organ function by ensuring sufficient fluid intake. The best method for assessing the results of fluid resuscitation is by monitoring urine output. A urine output of greater than 0.5 mL/kg/hr is indicative of adequate renal perfusion and kidney function, suggesting that fluid resuscitation is effective in maintaining tissue perfusion and preventing complications such as acute kidney injury.
B. Serum hemoglobin is 11 gm/dL
Serum hemoglobin levels can be affected by various factors, including fluid resuscitation, blood loss, and other medical conditions. While monitoring hemoglobin levels is important in overall patient assessment, it is not the best method specifically for assessing the results of fluid resuscitation during the initial phase of burn management.
C. Breath sounds are clear bilaterally
Clear bilateral breath sounds indicate adequate lung function and ventilation but may not directly reflect the effectiveness of fluid resuscitation in maintaining tissue perfusion. Lung sounds can be influenced by factors such as lung injury from smoke inhalation or mechanical ventilation settings, which may not correlate directly with fluid resuscitation outcomes.
D. Heart rate is 122/min
Heart rate can be influenced by various factors such as pain, stress, medications, and underlying medical conditions. While monitoring heart rate is important in assessing patient status, it is not the most reliable method for specifically evaluating the results of fluid resuscitation during the fluid resuscitation phase of burn management.
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