The nurse is caring for a client with deep partial-thickness and full-thickness burns to the chest area.
The client has T 100.4 F, P 100, R 24, and BP 102/60. The client is complaining of severe pain. Which assessment data is most concerning to the nurse?
The client's pulse oximeter reading is 95 percent.
The client's urinary output is 50 mL in two hours.
The client reports a pain level of 9 out of 10.
The client has localized edema around the burn site.
The Correct Answer is B
This scenario requires applying knowledge of burn pathophysiology, fluid resuscitation, and emergency prioritization. Assessing deep tissue damage involves monitoring for systemic complications such as hypovolemia or airway compromise. Critical thinking is needed to distinguish between expected post-burn symptoms and life-threatening physiological shifts.
Choice A rationale
A saturation of 95 percent is within the acceptable normal range of 95 to 100 percent. While chest burns can impact ventilation, this specific value indicates adequate oxygenation and is not currently a priority over circulatory concerns.
Choice B rationale
Normal urinary output is ≥ 0.5 mL/kg/hr or roughly 30 mL/hr. An output of 25 mL/hr indicates poor renal perfusion or hypovolemia. This suggests inadequate fluid resuscitation, which is a life-threatening complication in major burn injuries.
Choice C rationale
Pain is expected with partial-thickness burns due to exposed nerve endings. While severe pain requires intervention, it is considered a psychosocial or non-life-threatening priority compared to hemodynamic instability or organ failure signaled by low urine output.
Choice D rationale
Localized edema is a standard inflammatory response in burn victims caused by increased capillary permeability. It is an expected finding within the first 24 to 48 hours and does not indicate an immediate systemic crisis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The scenario requires application of neurobiological principles regarding right-sided cerebrovascular accidents. Knowledge of hemispatial neglect and safety interventions is essential to address visual field deficits. Prioritization focuses on promoting compensatory behaviors to ensure adequate nutritional intake and safety during meals.
Choice A rationale
Stroke damage to the right parietal lobe often results in unilateral neglect. While clinically expected, documentation is a secondary action that does not address the immediate physiological need for nutrition or safety while the client is currently eating.
Choice B rationale
Visual scanning techniques utilize conscious cognitive effort to bypass damaged neural pathways in the right hemisphere. Training the client to look left compensates for hemispatial neglect, ensuring they receive adequate nutrients and maintain awareness of their immediate environment.
Choice C rationale
Feeding assistance fosters dependence and does not encourage neuroplasticity or self-care. The nursing goal is to promote independence through rehabilitation strategies, such as environmental scanning, rather than performing tasks that the client can achieve with verbal cues.
Choice D rationale
Removing the food tray prevents the client from completing their meal, which could lead to nutritional deficits. Notifying the provider is unnecessary for an expected stroke symptom when nursing interventions like scanning can effectively manage the issue.
Correct Answer is A
Explanation
This clinical scenario focuses on postoperative care for split-thickness skin grafts and integumentary rehabilitation. Knowledge of tissue fragility, ultraviolet radiation sensitivity, and wound healing phases is required to prevent graft failure, hyperpigmentation, and secondary injury during the remodeling phase.
Choice A rationale
Newly grafted skin lacks melanocytes and the protective epidermal barrier, making it highly susceptible to ultraviolet damage. Direct sunlight can cause severe sunburn and permanent hyperpigmentation. Protection ensures long-term graft viability and prevents tissue degradation.
Choice B rationale
Physical therapy is vital to prevent contractures and maintain range of motion in burned limbs. While necessary for functional recovery, it is not the immediate priority over preventing physical damage to the fragile graft site from environmental factors.
Choice C rationale
Cosmetic camouflage helps manage the psychological impact of scarring and skin discoloration. While important for holistic recovery and body image, it is a psychosocial intervention that ranks lower than physiological protection of the surgical graft site.
Choice D rationale
Burn recovery requires a high-protein, high-calorie diet to support tissue synthesis and positive nitrogen balance. A low-protein diet would be contraindicated as it impairs collagen formation and delays wound healing in recovering burn patients.
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