A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about.
What action by the nurse is most appropriate?

Choice A rationale

Burn injuries, especially those affecting the face, neck, and chest, significantly increase the risk of smoke inhalation and airway edema. Administering oxygen is crucial to counteract potential hypoxia resulting from impaired gas exchange in the lungs, carbon monoxide poisoning, and cellular anoxia. The goal is to maintain adequate tissue oxygenation and prevent respiratory failure, which is a leading cause of mortality in burn victims.

Choice B rationale

Fluid restriction is contraindicated in burn patients because they experience massive fluid shifts from the intravascular space into the interstitial spaces due to increased capillary permeability caused by the inflammatory response. This leads to hypovolemia and burn shock. Aggressive fluid resuscitation is necessary to maintain adequate circulating blood volume, tissue perfusion, and kidney function, preventing multi-organ system failure.

Choice C rationale

Assessing for airway patency is the absolute priority in a patient with burns to the face, neck, and chest. The heat and smoke can cause immediate laryngeal edema and subsequent upper airway obstruction, which can be life-threatening. The nurse must continuously monitor for signs such as stridor, hoarseness, and dyspnea, and prepare for potential intubation to secure the airway.

Choice D rationale

Elevating the extremities is a vital intervention for burn patients without fractures. The purpose of elevation is to reduce edema formation by promoting venous return and decreasing hydrostatic pressure in the burned limbs. This helps to maintain circulation, minimize tissue damage, and reduce pain. Edema is a major complication of burns due to the inflammatory response and increased capillary permeability.

Choice E rationale

Placing a cooling blanket on a burn patient is inappropriate and can be harmful. While cooling the burn area itself can decrease the inflammatory response, excessive cooling of the entire body, especially a large surface area, can lead to systemic hypothermia. Hypothermia impairs coagulation, decreases cardiac output, and can increase the risk of infection, all of which are detrimental to a burn patient.

Choice A rationale

Hypertension is not a typical finding in a patient with a pulmonary embolism. The body's response to a significant blockage in the pulmonary arteries is often a decrease in cardiac output due to increased right ventricular afterload. This can lead to a compensatory drop in systemic blood pressure, resulting in hypotension rather than hypertension. Hypertension is a less common finding and usually occurs only with very small emboli.

Choice B rationale

Tachycardia is a very common and expected manifestation of a pulmonary embolism. The embolism causes a ventilation-perfusion mismatch and hypoxemia. The body compensates for the reduced oxygenation by increasing the heart rate to improve cardiac output and oxygen delivery to the tissues. Additionally, the release of inflammatory mediators and catecholamines in response to the physiological stress also contributes to an elevated heart rate.

Choice C rationale

Petechiae are small, pinpoint hemorrhages under the skin. They are typically associated with disorders of platelet function, such as thrombocytopenia, or small vessel vasculitis. They are not a direct manifestation of a pulmonary embolism. A pulmonary embolism is a thrombotic event within the pulmonary arteries and does not cause a systemic microvascular hemorrhage that would present as petechiae on the skin.

Choice D rationale

Bradypnea, or an abnormally slow respiratory rate, is not an expected finding in a patient with a pulmonary embolism. The hypoxemia and physiological stress caused by the embolism trigger a compensatory increase in the respiratory rate to improve oxygen intake. The patient will likely present with tachypnea, a rapid respiratory rate (normal range is 12-20 breaths/min), as they struggle to overcome the respiratory compromise and ventilate adequately. ---.