During prehospital care, what is the nurse's priority action for a burn victim?

Providing oral fluids

Stopping the burning process

Covering with warm blankets

Giving morphine

Answer and Explanation

The Correct Answer is B

A. Providing oral fluids: While fluid replacement is important in burn victims, oral intake in the prehospital setting may be limited by airway compromise, nausea, or altered consciousness. Immediate fluid resuscitation is often deferred until intravenous access is established in a controlled setting.

B. Stopping the burning process: The priority in prehospital burn care is to halt the source of injury to prevent further tissue damage. This may involve extinguishing flames, removing the patient from hot surfaces, or chemical decontamination. Controlling the burn source directly limits injury progression and is the first and most critical intervention.

C. Covering with warm blankets: Covering the patient helps prevent hypothermia, which is a significant concern in extensive burns, but it is a secondary action after ensuring the burn source is eliminated. Warm blankets support stabilization but do not stop ongoing tissue damage.

D. Giving morphine: Pain management is essential, but analgesics do not prevent further injury. Administering morphine is secondary to stopping the burn source, securing the airway, and stabilizing the patient. Pain control is provided once the patient is safe from ongoing harm.

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Correct Answer is A

Explanation

A. Determine a Glasgow Coma Scale score: Assessing the patient’s level of consciousness using the Glasgow Coma Scale (GCS) is the most urgent step when increased ICP is suspected. Changes in mental status are often the earliest and most sensitive indicator of rising ICP, and a rapid, structured assessment allows the nurse to identify neurologic deterioration promptly.

B. Obtain heart rate and blood pressure: Vital signs provide important information about hemodynamic status and may indicate Cushing’s triad in late-stage ICP elevation, but changes in consciousness usually precede these vital sign alterations. Immediate neurologic assessment takes priority.

C. Assess reflexes and push pulls of feet: Reflex testing and motor strength evaluation are components of a comprehensive neurologic assessment, but they are secondary to establishing the patient’s overall level of consciousness and GCS score. Delaying initial assessment could postpone recognition of acute deterioration.

D. Assess for nuchal rigidity: Nuchal rigidity is a sign of meningeal irritation, not a primary indicator of increased ICP following a craniotomy. While important to note, it is not the first assessment action when acute neurologic changes and signs of herniation are present.

A. Capillary refill less than three (3) seconds B. Pulse oximeter reading of 95% C. An enlarged spleen D. Petechiae on the anterior chest, arms, and neck

Correct Answer is D

Explanation

A. Capillary refill less than three (3) seconds: A normal capillary refill indicates adequate peripheral perfusion and is not a typical finding associated with idiopathic thrombocytopenic purpura (ITP), which primarily affects platelet count and bleeding tendencies rather than perfusion.

B. Pulse oximeter reading of 95%: Oxygen saturation reflects respiratory function and is generally unaffected in ITP. This reading does not correlate with the hematologic manifestations of the disorder.

C. An enlarged spleen: Splenomegaly is more characteristic of secondary causes of thrombocytopenia, such as certain infections or hematologic malignancies. In classic ITP, the spleen is usually normal in size.

D. Petechiae on the anterior chest, arms, and neck: Petechiae are small, pinpoint hemorrhages resulting from platelet deficiency and are a hallmark sign of ITP. They appear on areas prone to pressure or trauma and indicate the patient’s increased risk for bleeding due to thrombocytopenia.

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During prehospital care, what is the nurse's priority action for a burn victim?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which sign would the nurse expect to assess in the patient diagnosed with idiopathic thrombocytopenic purpura (ITP)?

Correct Answer is D

Explanation

Six hours after a thermal burn, the nurse obtains the following assessment data for a patient who weighs 70 kg and has a 50% total body surface area (TBSA) burn. Which information is most important to communicate to the health care provider?

During prehospital care, what is the nurse's priority action for a burn victim?

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