A patient is being treated for facial bums caused by a house fire. Which assessment should the nurse make a priority?

Checking for airway patency

Capillary refill time

Ability to speak

Presence of a gag reflex

Answer and Explanation

The Correct Answer is A

A. Checking for airway patency: In patients with facial burns from a house fire, airway compromise from thermal injury, edema, or inhalation of smoke and toxic gases is the most immediate threat to life. Early recognition and management of airway obstruction are critical to prevent hypoxia and respiratory failure, making airway assessment the top priority.

B. Capillary refill time: Capillary refill provides information about peripheral perfusion and circulation. While important in burn patients who may develop hypovolemia, it is secondary to airway assessment, as inadequate oxygenation is immediately life-threatening.

C. Ability to speak: The ability to speak may help assess airway status, but it is an indirect measure. Airway patency can be compromised even if the patient can initially speak, so direct assessment of airway, breathing, and oxygenation takes precedence.

D. Presence of a gag reflex: The gag reflex indicates protective airway reflexes, which is relevant for intubation or aspiration risk. However, in acute burn injuries with facial edema or inhalation injury, actual airway obstruction can occur rapidly, so assessment of patency and readiness for intervention is more urgent.

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Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

Rationale for Correct Answers:

Supraventricular tachycardia: The telemetry strip shows a rapid, regular rhythm originating above the ventricles, consistent with supraventricular tachycardia (SVT), and the heart rate is above 150 beats per minute. SVT can cause palpitations, dizziness, or hypotension if sustained, making accurate identification critical for timely intervention.

Administering adenosine: Adenosine is the first-line pharmacologic treatment for stable SVT. It transiently blocks AV nodal conduction, which can terminate the reentrant tachycardia and restore normal sinus rhythm. Administration requires rapid IV push with immediate saline flush and continuous monitoring due to potential transient bradycardia or brief asystole.

Rationale for Incorrect Answers

Atrial fibrillation: This rhythm is irregularly irregular with no identifiable P waves. SVT is regular and very rapid.

Sinus tachycardia: This has a normal P wave before every QRS complex and is typically caused by pain, fever, dehydration, or anxiety. It is not treated with adenosine.

Defibrillation: This is used for life-threatening rhythms such as ventricular fibrillation or pulseless ventricular tachycardia, not stable SVT.

Administering diltiazem: This is commonly used to control ventricular rate in atrial fibrillation, not as first-line treatment for SVT.

A. Maintain head of bed elevation at 15 degrees or less. B. Provide oxygen therapy to maintain oxygen saturation above 92 C. Keep lights dim in client's room to accommodate photophobia D. Assess the client for headaches and behavior changes frequently E. Minimize suctioning or hyper-oxygenate client before suctioning

Correct Answer is ["B","D","E"]

Explanation

A. Maintain head of bed elevation at 15 degrees or less: For a patient with increased intracranial pressure (ICP), the head of the bed should typically be elevated 30 degrees, not limited to 15 degrees. Proper elevation promotes venous drainage from the brain and helps reduce ICP, making 15 degrees insufficient for effective ICP management.

B. Provide oxygen therapy to maintain oxygen saturation above 92: Maintaining adequate oxygenation is critical in patients with neurological injury. Hypoxia can worsen cerebral ischemia and increase ICP, so oxygen therapy should be titrated to keep SpO₂ within the prescribed safe range, typically above 92%, to support cerebral perfusion and prevent secondary brain injury.

C. Keep lights dim in client's room to accommodate photophobia: While dim lighting can increase comfort in patients with migraine or photophobia, it does not directly affect ICP management. This action is supportive but not a priority intervention in caring for a patient with increased ICP.

D. Assess the client for headaches and behavior changes frequently: Frequent neurological assessment, including monitoring for changes in level of consciousness, behavior, and headache, is essential for early detection of worsening ICP or complications. These assessments guide timely interventions and are critical in intensive care management of post-stroke patients.

E. Minimize suctioning or hyper-oxygenate client before suctioning: Suctioning can stimulate coughing and increase ICP. To prevent sudden spikes in ICP, suctioning should be minimized and performed only when necessary, with pre-oxygenation to maintain cerebral oxygenation and reduce secondary brain injury risk.

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A patient is being treated for facial bums caused by a house fire. Which assessment should the nurse make a priority?

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Naxlex Comprehensive Predictor Exams

Based on the information in the electronic health record, complete the following sentences using the drop-down lists. The nurse reads the telemetry strip and interprets the client's cardiac rhythm asdropdown. Based on the cardiac rhythm and client assessment, the nurse anticipatesdropdown

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

The nurse cares for the client in the intensive care unit. Select all the nursing actions that apply.

Correct Answer is ["B","D","E"]

Explanation

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