Priority nursing diagnoses for burns include: (Select All That Apply)

Adequate Tissue Perfusion

Risk for infection

Impaired Gas Exchange

Acute Pain

Fluid Volume Deficit

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Airway obstruction
Burns involving the head, neck, or chest put the client at risk for inhalation injury or airway edema, which can rapidly become life-threatening.

B. Contractures
This is a long-term complication, not an immediate concern.

C. Infection
While a serious risk, it is not as immediate as airway obstruction in the acute phase.

D. Fluid imbalance
Important, especially within the first 24 hours, but airway compromise takes precedence when head/neck/chest burns are involved.

A. Restricted movement B. Reduced pain medications C. Decreased fluid resuscitation D. inflammation caused by the burn

Correct Answer is D

Explanation

A. Restricted movement:
May occur due to pain or immobilization but does not increase metabolic demand significantly.

B. Reduced pain medications:
May increase discomfort but does not directly increase the metabolic rate.

C. Decreased fluid resuscitation:
Leads to hypoperfusion and shock, not increased metabolism.

D. Inflammation caused by the burn:
Correct. Severe burns trigger a hypermetabolic response due to systemic inflammation, catecholamine release, and tissue repair demands.

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Priority nursing diagnoses for burns include: (Select All That Apply)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has partial-thickness and full-thickness burns of his head, neck, and chest. The nurse should recognize which of the following is the priority risk to the client?

Correct Answer is A

Explanation

The nurse is reviewing the care plan with the dietician or nutritionist for a burn client. The nurse knows which of the following factors contribute to the increased metabolic demands in burn patients?

Correct Answer is D

Explanation

The nurse at an HCP's office is interviewing a patient presenting with a skin infection. Which question by the nurse will provide the least important information?

A nurse is preparing to administer liquid mycostatin 600,000 units PO every 8 hr. Available is mycostatin 100,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.)

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

A nurse is admitting a client with severe burns. The nurse uses the rule of nines to estimate the percentage of total body surface area affected by burns. Which of the following statements accurately describes the rule of nines?

Which of the following assessments should the nurse prioritize for a burn patient with impaired physical mobility?

A nurse in a provider's office is collecting data from a client who has severe sunburn. Which of the following classifications should the nurse use to document this burn?

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?