Priority nursing diagnoses for burns include: (Select All That Apply)
Adequate Tissue Perfusion
Risk for infection
Impaired Gas Exchange
Acute Pain
Fluid Volume Deficit
Correct Answer : B,C,D,E
A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.
B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.
C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.
D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.
E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Minimal edema in the affected extremities:
Expected after 72 hours as inflammation begins to subside.
B. Temperature of 39.1°C (102.4°F):
Elevated temperature may indicate infection or systemic inflammation and should be reported.
C. Pain at the burn sites:
Pain is expected, especially in partial-thickness burns where nerve endings are exposed.
D. Urine output of 30 mL/hr:
While on the lower end of normal, this is still acceptable for an adult (minimum: 30 mL/hr).
Correct Answer is D
Explanation
A. Reports of joint discomfort:
Not typically associated with contact dermatitis.
B. Elevated temperature:
Systemic symptoms like fever are not common in localized contact dermatitis.
C. Denial of pruritus:
Itching (pruritus) is a hallmark symptom of contact dermatitis.
D. Reports of exposure to a skin irritant:
Contact dermatitis occurs following direct contact with an irritant or allergen.
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