A nurse is caring for a client with sudden-onset bilateral lower extremity edema and redness caused by altered tissue integrity.
What is the critical intervention based on the client's condition?
Perform heart failure screening.
Conduct motor strength testing.
Administer pain medications.
Prepare saline wound dressing.
The Correct Answer is A
Choice A rationale
Sudden onset of bilateral lower extremity edema often indicates a systemic failure rather than a localized integumentary issue, necessitating an evaluation of cardiac function. Normal central venous pressure ranges from 2 to 8 mmHg, and elevations can lead to peripheral fluid shifts. Heart failure screening is the priority to identify if the heart is failing to pump effectively, causing venous congestion and increased hydrostatic pressure that forces fluid into the interstitial spaces.
Choice B rationale
Assessing the ability of the patient to move their limbs or checking deep tendon reflexes provides information about the neurological system but does not address the immediate physiological cause of acute fluid accumulation. While motor function is important for overall health, it is not the most life-threatening concern when a client presents with rapid-onset bilateral swelling. The nurse must first stabilize or identify the primary circulatory or systemic deficit before performing detailed musculoskeletal or neurological exams.
Choice C rationale
Analgesics may provide symptomatic relief for the discomfort associated with skin stretching or inflammation, but they do not treat the underlying pathophysiology of the edema. Focusing solely on pain management ignores the potential for systemic complications such as pulmonary edema or renal failure. Scientific nursing practice dictates that the practitioner must address the etiology of the altered tissue integrity to prevent further deterioration of the client’s hemodynamic status and overall clinical stability.
Choice D rationale
While topical dressings are useful for open lesions, the primary issue described is systemic edema and redness, which suggests an internal fluid shift rather than a primary external wound. Using saline dressings without addressing the cause of the swelling would be an incomplete intervention. The nurse must recognize that bilateral symptoms usually point toward a central cause like cardiac or renal insufficiency, requiring a comprehensive assessment of the patient's fluid volume status.
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Related Questions
Correct Answer is B
Explanation
Choice A rationale
While capillary refill time is an indicator of peripheral perfusion and should be within 2 to 3 seconds, it is not the highest priority for burns involving the chest. Peripheral circulation is important for assessing fluid resuscitation status and cardiac output, but it does not address immediate threats to life. In the hierarchy of trauma assessment, circulation follows the stabilization of the airway and the adequacy of the patient's breathing and ventilation.
Choice B rationale
Burns covering the chest carry a significant risk for inhalation injury and compromised chest wall expansion. The nurse must prioritize lung sounds and respiratory effort to detect stridor, wheezing, or decreased breath sounds which indicate airway edema or smoke inhalation. Inhalation of hot gases can cause rapid swelling of the glottis and subglottic structures. Ensuring a patent airway and adequate gas exchange is the most critical intervention in the emergent phase of burn care.
Choice C rationale
Pain assessment using a standardized score is necessary for patient comfort and to guide analgesic administration, particularly for partial-thickness burns which are extremely painful due to exposed nerve endings. However, pain is considered a secondary assessment compared to the respiratory system. While uncontrolled pain can increase metabolic demand and heart rate, it is not immediately life-threatening. The nurse addresses pain only after ensuring that the patient's airway and breathing are fully stabilized.
Choice D rationale
Assessing skin color and moisture helps determine the depth and severity of the burn, which is essential for calculating fluid requirements and planning wound care. Partial-thickness burns typically appear red, blistered, and moist. While this data is important for the overall treatment plan, it remains a lower priority than assessing for respiratory distress. Skin assessments are part of the secondary survey performed after the primary ABC assessment has been thoroughly completed and managed.
Correct Answer is A
Explanation
Choice A rationale
Maintaining a urine output of 30 to 50 mL per hour is the gold standard indicator that fluid resuscitation is effectively restoring organ perfusion. This volume suggests that the kidneys are receiving enough blood to maintain a normal glomerular filtration rate. In burn patients, adequate urine production confirms that the intravascular volume has been sufficiently replaced to overcome the massive fluid shifts and capillary leak syndrome that occur immediately following a significant thermal injury.
Choice B rationale
A heart rate greater than 120 beats per minute is usually an indicator of ongoing stress, pain, or hypovolemia rather than successful resuscitation. Tachycardia suggests that the heart is still working excessively hard to maintain cardiac output in the face of low blood volume. A successful resuscitation should ideally lead to a stabilization of the heart rate towards a more normal range, typically below 110 beats per minute, as the intravascular volume is restored and sympathetic drive decreases.
Choice C rationale
While some weight gain is expected during the acute phase of burn care due to the administration of large volumes of crystalloid fluids and subsequent edema, an increase of 5 percent is not a specific indicator of successful resuscitation. Excessive weight gain can actually signal fluid overload or third-spacing rather than effective intravascular volume replacement. The goal of resuscitation is to support vital organ function with the least amount of fluid necessary, avoiding complications like pulmonary edema.
Choice D rationale
Decreased peripheral pulses are a concerning sign that may indicate inadequate systemic perfusion or localized compartment syndrome due to circumferential burns and excessive edema. Successful fluid resuscitation should result in the maintenance or improvement of peripheral pulses, indicating that blood is reaching the distal extremities. If pulses are weakening, it suggests that the circulatory status is deteriorating or that fluid is accumulating in the interstitial spaces so severely that it is compressing the arterial flow.
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