A nurse is caring for a client with severe burn injury admitted from the emergency room.
Which of the following assessments should the nurse prioritize for this client?
Assessing airway and breathing.
Assessing medication history.
Assessing bowel sounds.
Assessing urinary output.
The Correct Answer is A
Choice A rationale
In burn injury, prioritizing airway and breathing is paramount due to potential inhalation injury, upper airway edema, and compromise of respiratory function. Flames and smoke can cause direct thermal injury to the airway, leading to rapid swelling and obstruction, or chemical irritation from smoke inhalation, impacting gas exchange. Securing the airway prevents life-threatening respiratory distress.
Choice B rationale
While assessing medication history is important for comprehensive care, it is secondary to immediate life-threatening concerns in a severe burn injury. An accurate medication history can inform treatment decisions regarding pain management, infection control, and pre-existing conditions, but it does not address the immediate physiological stability of the client's airway and breathing.
Choice C rationale
Assessing bowel sounds is part of a comprehensive gastrointestinal assessment. However, in the acute phase of severe burn injury, the focus is on systemic stability and vital organ function. Bowel sounds may be diminished due to stress response or paralytic ileus, but this assessment does not take precedence over establishing a patent airway and ensuring adequate ventilation.
Choice D rationale
Assessing urinary output is crucial for monitoring renal perfusion and fluid status in burn clients, indicating the adequacy of fluid resuscitation. While essential, it follows the immediate stabilization of airway and breathing. Inadequate urinary output signifies hypovolemia or renal compromise, but securing the airway and ensuring ventilation are the primary and most immediate life-saving interventions.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Palpitations, described as feeling the heart skip a beat, can be a symptom of various cardiac conditions, including arrhythmias, but are not singularly indicative of aortic stenosis. While aortic stenosis can lead to arrhythmias, palpitations are not the most specific or common initial complaint directly correlating with the physiological changes of a narrowed aortic valve.
Choice B rationale
Dyspnea on exertion, or shortness of breath with exercise, is a cardinal symptom of aortic stenosis. As the aortic valve narrows, the left ventricle must generate increasingly higher pressures to eject blood into the aorta. During exercise, cardiac output demands increase, and the stenosed valve restricts blood flow, leading to exertional dyspnea due to elevated left ventricular end-diastolic pressure and pulmonary congestion.
Choice C rationale
Pitting edema in the feet and ankles suggests fluid retention, which is a common manifestation of right-sided heart failure. While severe aortic stenosis can eventually lead to biventricular heart failure, peripheral edema is not typically the earliest or most specific symptom directly linked to the mechanical obstruction of the aortic valve itself. It is a later manifestation of cardiac decompensation.
Choice D rationale
Chest pain that resolves with rest is characteristic of stable angina, often caused by coronary artery disease. While patients with severe aortic stenosis can experience anginal chest pain due to increased myocardial oxygen demand from ventricular hypertrophy and reduced coronary perfusion, this symptom is not as specific to aortic stenosis as exertional dyspnea, which directly reflects the flow obstruction.
Correct Answer is ["6300"]
Explanation
Step 1: Convert the client's weight from pounds to kilograms. 231 pounds ÷ 2.2 pounds/kg = 105 kg.
Step 2: Calculate the total units of heparin for the bolus. 60 units/kg × 105 kg = 6300 units. The nurse will give 6300 units of heparin for the bolus.
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