The client is admitted to the emergency department with a full-thickness burn over the front of both legs.
Which priority intervention should the nurse implement?
Maintain a sterile environment when caring for the client.
Assess the client's pain level on a 1 to 10 pain scale.
Administer intravenous antibiotic therapy.
Prepare to administer a large volume of Lactated Ringer's solution.
The Correct Answer is D
Full thickness burns trigger massive systemic inflammatory responses and capillary leak syndrome. The clinical priority is addressing hypovolemic shock through aggressive fluid resuscitation to maintain organ perfusion, particularly when large surface areas like both legs are involved.
Choice A rationale
Sterile environments prevent secondary infections and sepsis in denuded skin areas. While infection control is vital in burn management, it is a secondary goal compared to the immediate physiological threat of hypovolemic shock and cardiovascular collapse.
Choice B rationale
Pain assessment is standard nursing practice, yet full thickness burns often destroy nerve endings, potentially resulting in less pain than partial thickness burns. Regardless, physiological stabilization and fluid replacement take precedence over subjective pain scaling in emergencies.
Choice C rationale
Prophylactic antibiotics are not typically the initial priority in acute burn care. Fluid resuscitation and airway management are paramount. Systemic antibiotics are usually reserved for documented infections rather than immediate emergency department stabilization of fluid status.
Choice D rationale
Burn injuries cause significant fluid shifts from the intravascular to the interstitial space. Administering Lactated Ringer solution is the gold standard for restoring volume and preventing acute tubular necrosis or organ failure during the first 24 hours.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Managing chronic kidney disease requires understanding the reciprocal relationship between calcium and phosphorus. Knowledge of renal osteodystrophy, vitamin D activation, and the role of the parathyroid hormone in mineral homeostasis is essential to identify the associated electrolyte shift.
Choice A rationale
Hypokalemia is not the primary association with hypocalcemia in kidney failure. Chronic kidney disease usually results in hyperkalemia, where potassium exceeds 5.0 mEq/L, because the failing kidneys cannot effectively excrete excess potassium ions into the urine.
Choice B rationale
Hypernatremia is an elevation of sodium above 145 mEq/L and is not directly linked to the calcium-phosphorus axis. While fluid balance is impaired in renal failure, sodium levels vary based on fluid volume status rather than hypocalcemia.
Choice C rationale
In kidney failure, phosphorus excretion decreases, leading to hyperphosphatemia. High serum phosphorus (above 4.5 mg/dL) binds with calcium, causing hypocalcemia (below 8.5 mg/dL). Additionally, decreased vitamin D activation in the kidneys further reduces calcium absorption from the gut.
Choice D rationale
Hyponatremia, or sodium below 135 mEq/L, often results from fluid overload in renal patients but is not the metabolic driver of low calcium. The hallmark mineral imbalance involves the inverse relationship specifically between serum phosphate and ionized calcium.
Correct Answer is D
Explanation
This case focuses on managing urolithiasis with signs of potential urinary obstruction. Knowledge of the nursing process, prioritization of physiological needs, and the distinction between pain management and critical organ perfusion/output is necessary to determine the first action.
Choice A rationale
Straining urine is important for stone analysis but is not the immediate priority for a client who hasn't voided in 6 hours. Assessment of the underlying cause of urinary retention must occur before focusing on stone recovery procedures.
Choice B rationale
Encouraging fluids helps flush stones but may exacerbate pain or vomiting if a total obstruction is present. The client's lack of output for 6 hours requires an assessment of bladder status before increasing fluid load significantly.
Choice C rationale
Pain management is essential for urolithiasis, but the lack of urinary output is a physiological priority. Assessing for bladder distention or obstruction ensures the kidneys are not sustaining damage from hydronephrosis before focusing solely on symptomatic relief.
Choice D rationale
Assessing for bladder distention is the priority to determine if the client is experiencing urinary retention due to obstruction. Identifying whether urine is being produced but trapped in the bladder is critical for preventing renal injury and hydronephrosis..
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