A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

Remove clothing and jewelry but avoid peeling off adhered skin

Establish IV access and initiate fluid resuscitation

Prepare for wound care and Wound debridement

Assess for smoke inhalation injury and airway swelling

Answer and Explanation

The Correct Answer is D

A. Remove clothing and jewelry but avoid peeling off adhered skin. While removing clothing and jewelry is necessary to prevent further tissue damage and swelling, it is not the highest priority in the initial assessment. Airway assessment must come first.

B. Establish IV access and initiate fluid resuscitation. Fluid resuscitation is crucial to prevent hypovolemic shock, but airway assessment and management take priority, especially in burns affecting the face, neck, and upper chest.

C. Prepare for wound care and wound debridement. Wound care is important but is not the first priority in emergency management. The airway must be secured first before addressing other concerns.

D. Assess for smoke inhalation injury and airway swelling. The greatest risk in burn patients, especially those with burns to the face, neck, or chest, is airway compromise due to inhalation injury or swelling. Airway assessment and securing the airway take priority before fluid resuscitation or wound care.

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Correct Answer is D

Explanation

A. Hematocrit 40%: A hematocrit level of 40% is within the normal range for adult females (36%-48%) and does not require intervention.

B. Potassium 3.8 mEq/L: Normal potassium levels range from 3.5-5.0 mEq/L, so a value of 3.8 mEq/L is within normal limits and does not pose a risk for surgery.

C. Creatinine 0.9 mg/dL: Normal creatinine levels for adult females are 0.5-1.1 mg/dL. A level of 0.9 mg/dL indicates normal kidney function and does not require reporting.

D. WBC count 20,000/mm³: A WBC count of 20,000/mm³ is significantly elevated, indicating a possible infection or inflammatory response. This increases the risk of post-operative complications and should be reported to the surgeon immediately.

A. Initiate fluid resuscitation. B. Insert an indwelling urinary catheter. C. Maintain the airway. D. Medicate for pain.

Correct Answer is C

Explanation

A. Initiate fluid resuscitation. Fluid resuscitation is critical to prevent hypovolemic shock, but airway maintenance takes precedence, especially in burns involving the chest and upper body.

B. Insert an indwelling urinary catheter. Urinary catheter insertion is important for monitoring urine output and assessing renal function, but it is not the first priority.

C. Maintain the airway. Burns to the chest, neck, and face increase the risk of airway edema and compromise. The nurse should assess for signs of inhalation injury, hoarseness, or stridor and prepare for early intubation if necessary.

D. Medicate for pain. Pain management is important but is not the highest priority in the resuscitation phase when securing the airway and preventing hypoxia are more critical.

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A nurse is providing initial emergency care for a client with extensive burns. Which of the following interventions should the nurse perform first?

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