The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

chemical burns to the posterior neck, chest, and back

radiation burns to shoulder and bridge of nose

electrical burns to the hands causing dysrhythmias

thermal burns to the head, neck, face, and airway.

Answer and Explanation

The Correct Answer is D

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

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Correct Answer is A

Explanation

A) Take the prescribed anticoagulant specifically as directed:
Clients with mechanical heart valves are at an increased risk of developing blood clots, and therefore, anticoagulation therapy (often warfarin or another blood thinner) is necessary to prevent thromboembolic events. It is essential for the client to take the prescribed anticoagulant exactly as directed, ensuring therapeutic levels are maintained while minimizing the risk of bleeding.

B) Stop taking your antihypertensive medications until checking:
This instruction is not appropriate after heart surgery. Antihypertensive medications are typically necessary to manage blood pressure and reduce the strain on the heart. Stopping antihypertensive medications without consulting the healthcare provider could result in elevated blood pressure, which can put undue stress on the heart, especially after valve replacement surgery.

C) Avoid lifting objects ten pounds or greater for two days:
This statement is not appropriate for a client who has undergone open heart surgery. After heart surgery, particularly valve replacement, the client may be advised to avoid lifting heavy objects for a period of time (often 4-6 weeks) to prevent strain on the incision site and the heart. Two days of restriction is insufficient; longer periods of activity limitation are usually required to ensure proper healing.

D) Take your immunosuppressive medications daily in the morning:
Immunosuppressive medications are not typically prescribed for clients with mechanical heart valves. Immunosuppressive drugs are usually prescribed for clients who have had organ transplants (e.g., kidney, liver) to prevent organ rejection. Since the client in this scenario had a mitral valve replacement, immunosuppressants are not usually indicated unless there are specific complications, such as endocarditis or other infections.

A. Tachycardia B. Crackles C. Ascites D. Dyspnea E. Peripheral edema

Correct Answer is ["A","B","D"]

Explanation

A) Tachycardia: Tachycardia is commonly seen in left-sided heart failure as the heart attempts to compensate for the reduced cardiac output. To maintain adequate perfusion, the body increases the heart rate. The sympathetic nervous system is activated, causing an increase in heart rate to try to pump blood more efficiently despite the reduced pumping ability of the left ventricle.

B) Crackles: Crackles (also known as rales) are typically heard upon auscultation of the lungs in patients with left-sided heart failure. When the left ventricle fails to effectively pump blood, it causes blood to back up into the lungs, resulting in pulmonary congestion. This leads to fluid accumulation in the alveoli, causing crackling sounds during inhalation.

C) Ascites: Ascites is more commonly seen in right-sided heart failure or in cases of congestive heart failure where both sides of the heart are affected. Ascites is the accumulation of fluid in the abdomen, which is a consequence of right-sided heart failure causing blood to back up into the abdomen. In left-sided heart failure, ascites is generally not a primary symptom unless the failure becomes severe and involves both sides of the heart.

D) Dyspnea: Dyspnea, or shortness of breath, is a hallmark symptom of left-sided heart failure. The left ventricle's inability to pump blood efficiently leads to pulmonary congestion, which causes fluid to accumulate in the lungs. This fluid buildup reduces the lung's ability to exchange oxygen, resulting in difficulty breathing, especially on exertion or when lying down (orthopnea).

E) Peripheral edema: Peripheral edema is more characteristic of right-sided heart failure due to the backup of blood in the systemic circulation. While it can occur in cases of biventricular heart failure (both right and left sides of the heart are affected), it is not the primary finding in left-sided heart failure. Left-sided heart failure typically presents with pulmonary symptoms rather than systemic symptoms like peripheral edema.

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The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

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Explanation

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Explanation

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