A nurse is caring for a patient who has a pneumothorax and whose vitals show low blood pressure.

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

A penetrating chest wound can lead to pneumothorax, hemothorax, or flail chest, all of which compromise the patient's ability to breathe and exchange gases effectively. The immediate and most life-threatening consequence is acute respiratory failure. Therefore, the highest priority goal is to restore adequate gas exchange to ensure proper oxygenation of the blood and removal of carbon dioxide. This goal supersedes all others.

Choice B rationale

While effective coping is important for a patient with a long-term illness or injury, it is a psychosocial goal that is not prioritized over the immediate physiological need for life support. Coping mechanisms cannot be addressed until the patient's immediate and life-threatening medical conditions, such as respiratory failure, are stabilized.

Choice C rationale

Facilitation of long-term intubation is not a primary goal of treatment; rather, it is a potential intervention to achieve the primary goal of restoring gas exchange. The ultimate goal is to wean the patient off mechanical ventilation and extubate them as soon as medically possible, not to keep them on the ventilator long-term. The intervention is a means to an end, not the end itself.

Choice D rationale

Self-management of oxygen therapy is a long-term goal that is only applicable to patients who survive the acute phase of their illness and require supplemental oxygen at home. This goal is not appropriate for a patient in acute respiratory failure in a hospital setting. The immediate priority is the stabilization of the patient and restoration of normal respiratory function, not patient education for home care