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. Follows an object with eyes without nystagmus or strabismus
Cranial nerves III (oculomotor), IV (trochlear), and VI (abducens) control eye movement. CN XI does not control eye movement.

B. Moves the tongue out midline without tremors or deviation
Cranial nerve XII (hypoglossal nerve) controls tongue movement.

C. Moves the head and shoulders against resistance with equal strength
Cranial nerve XI (spinal accessory nerve) controls the sternocleidomastoid and trapezius muscles. If intact, the client can shrug shoulders and turn the head against resistance with equal strength.

D. Demonstrates full range of the neck
Full range of motion in the neck involves multiple muscles, not just those innervated by CN XI.

A. Deep purple erythema B. Facial nerve deficits C. Dysphonia or dysphagia D. Heart rate of 10 and blood pressure of 96/68

Correct Answer is C

Explanation

A. Deep purple erythema

This suggests bruising or possible hematoma formation, which is concerning but may not be immediately life-threatening.

B. Facial nerve deficits

This indicates nerve injury, which is serious but may not be immediately life-threatening.

C. Dysphonia or dysphagia

Dysphonia (difficulty speaking) or dysphagia (difficulty swallowing) are signs of airway compromise or injury to structures involved in breathing and swallowing. This requires immediate attention.

D. Heart rate of 100 and blood pressure of 96/68

These vital signs indicate tachycardia and borderline hypotension, which are concerning, but the airway compromise (option C) is more immediately life-threatening.

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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

The nurse is testing the function of cranial nerve XI (Spinal accessory nerve). Which finding would the nurse expect if the nerve is intact?

Correct Answer is C

Explanation

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

Correct Answer is C

Explanation

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The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

The nurse is caring for a client, with no other pertinent medical history, who was burned over 709% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.