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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. White Blood Cell decrease
Platelet transfusions do not affect WBC levels. WBCs may change in response to infection or inflammation, but this is not an indicator of successful platelet transfusion.
B. Platelets increase
The primary goal of platelet transfusion is to increase platelet count to reduce bleeding risk in thrombocytopenia.
C. Hemoglobin increase
Hemoglobin levels increase after red blood cell (RBC) transfusions, not platelet transfusions.
D. PT and INR normalize
PT/INR measures clotting function, which is affected by clotting factors, not platelets. Platelet transfusions do not directly correct prolonged PT/INR.
Correct Answer is D
Explanation
A. Avoid using an electric razor
This is not directly relevant to trigeminal neuralgia management. Although it may be important for clients to avoid stimulating the face in general, an electric razor is not a specific concern for trigeminal neuralgia.
B. Meats should be served hot
Hot foods should actually be avoided, as extreme temperatures can trigger trigeminal neuralgia pain. Therefore, this recommendation is incorrect.
C. Teeth should be brushed prior to each meal
This is a reasonable recommendation for maintaining oral hygiene, but it does not specifically address managing trigeminal neuralgia pain. It is not as effective as the correct measure for managing trigeminal neuralgia.
D. Chew food on the unaffected side
Clients with trigeminal neuralgia may experience severe pain on one side of the face, especially when chewing. To reduce pain, it is recommended to chew food on the unaffected side to avoid triggering pain.
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