A patient with a burn injury is in the emergent phase of care.
What is the priority nursing intervention for maintaining tissue integrity?
Apply topical antimicrobials to the wound.
Secure airway and provide oxygen support.
Perform daily debridement to prevent infection.
Initiate intravenous fluid resuscitation.
The Correct Answer is B
Choice A rationale
Applying topical antimicrobials is a necessary part of wound care, but it is not the priority during the emergent phase of a burn injury. The emergent phase focuses on immediate life-threatening issues according to the ABC priority framework. While preventing infection is important for long-term tissue integrity and healing, it must wait until the patient's physiological status is stabilized. Initial care centers on stabilization rather than local wound treatments that do not address systemic collapse.
Choice B rationale
Securing the airway and providing oxygen support is the absolute priority in the emergent phase of burn care, especially if inhalation injury is suspected. Hypoxia and airway obstruction from edema can lead to rapid death or systemic tissue ischemia. Ensuring adequate gas exchange is the first step in maintaining the integrity of all bodily tissues. Without a patent airway, no other interventions will be effective as the patient’s vital organs will quickly suffer from lack of oxygen.
Choice C rationale
Daily debridement is a secondary intervention used during the acute phase of burn recovery to remove necrotic tissue and promote healing. Performing debridement during the emergent phase is premature and could exacerbate physiological instability or fluid loss. The patient's immediate survival depends on hemodynamic and respiratory management rather than the removal of eschar. Debridement is a surgical or bedside procedure that occurs once the initial resuscitative efforts have been successfully completed.
Choice D rationale
Initiating intravenous fluid resuscitation is a vital intervention during the emergent phase to prevent hypovolemic shock, but it follows airway and breathing in the priority hierarchy. While maintaining circulating volume is essential for tissue perfusion, an unmanaged airway will kill the patient faster than fluid shifts. Once the airway is secure, aggressive fluid replacement using the Parkland formula is started to replace the massive losses caused by increased capillary permeability after a major thermal injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
Step 1 is 1 gram × 1000 mg ÷ 1 gram = 1000 mg.
Step 2 is (750 mg ÷ 1000 mg) × 2 mL = 1.5 mL. The nurse should administer 1.5 mL.
Correct Answer is B
Explanation
Choice A rationale
Flaky skin, or desquamation, is a non-specific finding that can be seen in various conditions, including chronic dermatitis or simple xerosis. It represents the shedding of the outermost layer of the epidermis and does not effectively differentiate between the deep bacterial infection of cellulitis and the more superficial inflammatory reaction of dermatitis. While it indicates a disturbance in skin barrier function, it lacks the diagnostic specificity required to confirm the presence of an acute infectious process.
Choice B rationale
The presence of pustules is a significant clinical cue that often points toward an infectious etiology, such as folliculitis or localized cellulitis, rather than simple contact dermatitis. Pustules contain purulent exudate consisting of white blood cells and cellular debris, signaling a primary immune response to bacteria like Staphylococcus aureus. While some forms of dermatitis can become secondarily infected, finding pustules early in the assessment prompts the clinician to investigate bacterial invasion more thoroughly through cultures.
Choice C rationale
A sunburn appearance, characterized by diffuse erythema, can be seen in both cellulitis and various types of dermatitis, such as actinic or contact dermatitis. Because both conditions involve vasodilation and increased blood flow to the skin, redness alone is not a reliable differentiator. Cellulitis typically presents with more distinct warmth and spreading borders, but the visual similarity to a sunburn makes it a poor diagnostic marker for distinguishing between the two inflammatory states.
Choice D rationale
Dry patches are common in many dermatological conditions, particularly atopic dermatitis or eczema, where the skin barrier is chronically compromised. While they indicate altered tissue integrity, they do not specifically suggest the deep tissue inflammation and infection characteristic of cellulitis. Cellulitis is more often associated with taut, shiny, and swollen skin rather than dry, scaly patches. Therefore, observing dry patches is more helpful for identifying chronic skin conditions rather than diagnosing an acute infection.
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