The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

Fluid resuscitation

Transfer to a burn center

Application of sterile dressings

Administer morphine 8mg IV.

Answer and Explanation

The Correct Answer is A

A. Fluid resuscitation

Burns covering a large TBSA result in massive fluid loss due to increased capillary permeability, leading to hypovolemic shock. Fluid resuscitation with lactated Ringer’s solution using the Parkland formula is the priority to restore intravascular volume and prevent organ failure.

B. Transfer to a burn center

While this patient requires specialized burn care, the immediate priority is fluid resuscitation. After initial stabilization, transfer to a burn center can be arranged.

C. Application of sterile dressings

Wound care is important, but it is not the priority in the emergent phase. Restoring circulation and preventing shock take precedence.

D. Administer morphine 8 mg IV

Pain management is crucial, but it is secondary to restoring intravascular volume and preventing hypovolemic shock.

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Correct Answer is C

Explanation

A. Inability to understand directions
The client's issue is with motor coordination, not comprehension.

B. Lesion of cranial nerve IX
Cranial nerve IX (Glossopharyngeal) is associated with swallowing and taste, not motor coordination.

C. Dysfunction of the cerebellum
The cerebellum controls coordination and fine motor movements. The client's inability to perform rapid alternating movements (dysdiadochokinesia) suggests cerebellar dysfunction.

D. Vestibular disease
Vestibular disorders cause dizziness, vertigo, and balance problems but do not typically affect rapid alternating movements.

A. The correct rate is 6 mL/hr to deliver 200 units/hr with a concentration of 200 units of heparin m B. After contacting the prescriber about the event Nurse A should an anticipate an order for IV Vitamin K C. The nurses will complete an event report due to the medication error D. Nurse A will document about the event report in the patients electronic medical record. E. The patient has received a dose of heparin over the prescribed amount F. The patient has received 3200 units of heparin from 1700-1900.

Correct Answer is ["C","E","F"]

Explanation

A. The correct rate is 6 mL/hr

The correct calculation should be verified.

B. After contacting the prescriber, Nurse A should anticipate an order for IV Vitamin K

Protamine sulfate, not vitamin K, is the antidote for heparin.

C. The nurses will complete an event report due to the medication error

A medication error must be reported.

D. Nurse A will document about the event report in the patient’s EMR

Incident reports are internal documents and should not be documented in the EMR.

E. The patient has received a dose of heparin over the prescribed amount

Due to the increased concentration, the patient received more heparin than intended.

F. The patient has received 3200 units of heparin from 1700-1900.

This calculation confirms overdosing.

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The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is ["C","E","F"]

Explanation

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