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 D

Explanation

A. Decrease chest pain is important but not the highest priority. Managing pain can help with breathing, but oxygenation is the primary concern.

B. Reduce the client's anxiety is secondary to physiological needs. Anxiety can worsen dyspnea, but addressing oxygenation first is more critical.

C. Maintain adequate circulating volume is a priority if there is hemorrhage, but the question does not indicate bleeding. Oxygenation takes precedence in this case.

D. Maintain adequate oxygenation is the priority. Chest trauma can lead to pneumothorax, pulmonary contusion, or other complications that can impair gas exchange. Ensuring adequate oxygenation prevents hypoxia and respiratory failure, which are life-threatening.

A. Provide the daughter and client with nutritional counseling B. Interview the client alone and assess for abuse C. Take the history from the daughter because of the client's confusion D. Request a psychiatric evaluation for the client

Correct Answer is B

Explanation

A. Provide the daughter and client with nutritional counseling.

While nutrition is important, assessing for abuse is the priority.

B. Interview the client alone and assess for abuse.

The client’s reluctance and daughter’s interruptions suggest potential elder abuse.

C. Take the history from the daughter due to the client’s confusion.

The client should be interviewed alone first.

D. Request a psychiatric evaluation.

Confusion can result from dehydration or trauma, not necessarily a psychiatric disorder.

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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?

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Naxlex Comprehensive Predictor Exams

A young adult is admitted to the emergency department after a motor vehicle crash. The client has severe pain in the right chest due to impact with the steering wheel. Which is the priority client goal?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

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