After receiving change-of-shift report on the burn unit, which patient would the nurse assess first?

A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

A patient with full-thickness leg burns who has a dressing change scheduled

A patient with 40% total body surface area (TBSA) bums who is receiving IV fluids at 500 mL/hour

A patient with smoke inhalation who has wheezes and altered mental status

Answer and Explanation

The Correct Answer is D

A. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain: Severe pain is expected in partial-thickness burns and requires prompt analgesia, but it does not typically represent an immediate life-threatening complication. Pain management is important but it does not supersede airway or breathing concerns in priority assessment.

B. A patient with full-thickness leg burns who has a dressing change scheduled: Full-thickness burns may be less painful due to nerve destruction, and a scheduled dressing change is a planned intervention. While wound care is essential to prevent infection and promote healing, it does not represent an urgent, unstable condition requiring immediate assessment at shift change.

C. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hour: A patient with extensive burns is at high risk for hypovolemic shock due to capillary leak and fluid shifts. If the patient is already receiving aggressive fluid resuscitation and there are no reported signs of instability, this reflects ongoing management

D. A patient with smoke inhalation who has wheezes and altered mental status: Smoke inhalation can lead to airway edema, bronchospasm, carbon monoxide poisoning, and impending airway obstruction. Wheezing suggests lower airway involvement, while altered mental status may indicate hypoxia or carbon monoxide toxicity. Airway and breathing take highest priority.

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Correct Answer is D

Explanation

A. Determine disability using the Glasgow Coma Scale: Assessing neurologic status with the Glasgow Coma Scale is important, but it is secondary to ensuring airway, breathing, and circulation. Immediate airway management takes priority in an unconscious patient with hypoventilation.

B. Obtain laboratory tests: Laboratory tests help identify the toxic agent and guide treatment, but collecting labs does not address the immediate life-threatening risk of hypoxia from inadequate ventilation.

C. Administer a central nervous system stimulant: Giving a CNS stimulant is not a safe or standard intervention for sedative overdose. Stimulants do not reverse respiratory depression and could worsen cardiovascular instability.

D. Maintain a patent airway: The patient’s respiratory rate is critically low (10 breaths/min), indicating hypoventilation and risk of hypoxia. Securing and maintaining a patent airway is the highest priority to ensure oxygenation and prevent respiratory arrest, following the ABCs of emergency care.

A. Pulse oximetry B. Chest x-rays C. Pulmonary artery pressure monitoring D. Arterial blood gas (ABG) analysis

Correct Answer is D

Explanation

A. Pulse oximetry: Pulse oximetry provides continuous monitoring of oxygen saturation but does not measure carbon dioxide levels or acid-base status. In ventilatory failure, hypoventilation can cause hypercapnia even if oxygen saturation is normal, making pulse oximetry insufficient for full assessment.

B. Chest x-rays: Chest x-rays can identify structural lung changes, infiltrates, or complications such as pneumothorax, but they do not provide real-time information about gas exchange or the effectiveness of ventilatory support.

C. Pulmonary artery pressure monitoring: Pulmonary artery catheters assess cardiac output and pulmonary pressures, which may be helpful in some critically ill patients, but they do not directly measure ventilation or gas exchange, which are central to evaluating ventilatory failure.

D. Arterial blood gas (ABG) analysis: ABGs provide direct measurement of PaO₂, PaCO₂, and pH, offering critical information about oxygenation, ventilation, and acid-base balance. These parameters are essential for determining the effectiveness of therapies such as mechanical ventilation, supplemental oxygen, or pharmacologic interventions in patients with ventilatory failure.

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After receiving change-of-shift report on the burn unit, which patient would the nurse assess first?

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