A patient with facial burns suddenly becomes restless with stridor. What is the nurse's priority action?

Administer IV morphine

Call for stat airway support

Elevate the HOB

Obtain ABG

Answer and Explanation

The Correct Answer is B

A. Administer IV morphine: Restlessness and stridor in a patient with facial burns strongly suggest impending airway obstruction due to edema or inhalation injury. Administering morphine may further depress respiratory drive and mask worsening airway compromise. Pain control is important but does not address the immediate threat of airway occlusion.

B. Call for stat airway support: Stridor indicates upper airway narrowing, and in the setting of facial burns, progressive edema can rapidly lead to complete airway obstruction. Early airway intervention, including preparation for endotracheal intubation, is critical before swelling makes intubation difficult or impossible. Securing the airway is the highest priority in burn management

C. Elevate the HOB: Elevating the head of the bed may help reduce facial edema and promote ventilation, but it is a supportive measure rather than a definitive intervention. It does not prevent rapid airway closure caused by burn-related swelling. Immediate airway management takes precedence.

D. Obtain ABG: Arterial blood gas analysis provides information about oxygenation and ventilation but does not treat airway compromise. Waiting for ABG results could delay lifesaving airway intervention. Clinical signs such as stridor and restlessness warrant immediate action to secure the airway.

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Correct Answer is B

Explanation

A. Coumadin: Coumadin (warfarin) is an oral anticoagulant that inhibits vitamin K–dependent clotting factors. It is not effective in reversing the anticoagulant effects of heparin and would not be appropriate in the event of a heparin overdose.

B. Protamine sulfate: Protamine sulfate is a heparin antagonist that binds to heparin to form a stable complex, neutralizing its anticoagulant effect. It is administered intravenously and acts rapidly, making it the drug of choice for treating heparin overdose or excessive anticoagulation.

C. Enoxaparin: Enoxaparin is a low-molecular-weight heparin and functions similarly to unfractionated heparin by enhancing antithrombin III activity. It is not an antidote and would worsen anticoagulation if administered during a heparin overdose.

D. Vitamin K: Vitamin K is used to reverse the effects of vitamin K–dependent anticoagulants such as warfarin. It has no direct effect on heparin-induced anticoagulation and is not suitable for managing heparin overdose.

A. Measure hourly urine output. B. Monitor daily weight. C. Check skin turgor. D. Assess mucous membranes.

Correct Answer is A

Explanation

A. Measure hourly urine output: In the emergent phase of burn injury, massive fluid shifts occur due to increased capillary permeability and third spacing. Hourly urine output is the most reliable and immediate indicator of adequate renal perfusion and effective fluid resuscitation. Maintaining urine output at approximately 0.5 mL/kg/hr in adults reflects sufficient circulating volume and organ perfusion.

B. Monitor daily weight: Daily weight is useful for evaluating overall fluid balance trends but is not sensitive enough for rapid assessment during the emergent phase. Fluid shifts in major burns occur quickly, requiring more immediate indicators than once-daily measurements.

C. Check skin turgor: Skin turgor is not a reliable indicator of fluid status in burn patients because skin integrity is compromised and edema is common. Burn injury alters the elasticity and appearance of the skin, limiting the usefulness of this assessment.

D. Assess mucous membranes: Mucous membrane moisture may provide general information about hydration status, but it does not accurately reflect intravascular volume in patients with significant burn injuries. Rapid capillary leak and fluid shifts require more precise monitoring parameters such as urine output.

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A patient with facial burns suddenly becomes restless with stridor. What is the nurse's priority action?

Nursing Test Bank

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Explanation

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