The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?

Increase oral fluids to 3000 mL/day.

Notify the primary care provider.

Monitor the patient for further changes in mental status.

Administer a prn dose of acetaminophen (Tylenol) for the fever.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Increasing oral fluids may support hydration, but in a patient with burns covering 45% of the body, the patient may already have complex fluid and electrolyte needs. Fluid management alone does not address the possibility of a life-threatening infection such as sepsis.

B. Notifying the primary care provider is the priority. Burns covering a large body surface area significantly increase the risk of infection and sepsis. A new fever accompanied by acute changes in mental status (agitation and confusion) are early signs of sepsis or systemic infection. Early recognition and prompt intervention, including possible blood cultures, antibiotics, and supportive care, are critical to prevent rapid deterioration.

C. Monitoring for further changes in mental status is important, but it is not the first action. Waiting to see if the patient worsens delays essential medical intervention for a potential life-threatening infection.

D. Administering acetaminophen can reduce fever temporarily, but it does not treat the underlying infection and could mask a key early indicator of sepsis. Treating the symptom without addressing the cause could delay urgent care.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is B

Explanation

Rationale:
A. Diphenhydramine (Benadryl) is incorrect as the first-line intervention because, although it blocks H1 histamine receptors and can reduce urticaria and itching, it does not act quickly enough to reverse airway obstruction, bronchospasm, or hypotension caused by anaphylaxis. Relying solely on diphenhydramine could result in progressive airway compromise or cardiovascular collapse.

B. Epinephrine is correct because the patient is experiencing anaphylactic shock, evidenced by rapid-onset airway compromise (stridor, hoarseness, lip edema) and circulatory collapse (hypotension, tachycardia, tachypnea). Epinephrine works immediately to vasoconstrict, increase blood pressure, reduce mucosal edema, and bronchodilate, making it the life-saving priority intervention.

C. Methylprednisolone (Solu-Medrol) is incorrect as the initial intervention because corticosteroids act slowly (hours) to reduce inflammation and cannot prevent imminent airway obstruction or restore blood pressure during acute anaphylaxis. They are considered adjunct therapy after epinephrine administration.

D. Ranitidine (Zantac) is incorrect because H2 blockers block histamine at H2 receptors, which may help reduce cutaneous symptoms or gastric acid effects but do not relieve airway edema, bronchospasm, or hypotension. They are used as secondary, supportive treatment after epinephrine, not as primary therapy.

A. administration of lactated Ringer's solution (1 L) wide open. B. chest x-ray study to determine the etiology of the symptoms. C. endotracheal intubation and mechanical ventilation. D. needle thoracostomy and chest tube insertion.

Correct Answer is D

Explanation

Rationale:
A. Administration of lactated Ringer's solution is incorrect because the patient is likely experiencing tension pneumothorax, not hypovolemic shock. Fluids alone will not relieve the life-threatening pressure in the pleural space.

B. Chest x-ray study is incorrect because tension pneumothorax is a clinical diagnosis and a medical emergency; waiting for imaging would delay life-saving treatment.

C. Endotracheal intubation and mechanical ventilation is incorrect because positive pressure ventilation can worsen a tension pneumothorax if the pleural pressure is not first relieved.

D. Needle thoracostomy and chest tube insertion is correct because the patient shows classic signs of tension pneumothorax: sudden hypotension, severe hypoxia, absent breath sounds on one side, and jugular venous distention. Immediate decompression with needle thoracostomy followed by chest tube placement is necessary to evacuate air, relieve pressure, and restore circulation and oxygenation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Ten minutes following administration of an antibiotic, the nurse assesses a patient to have edematous lips, hoarseness, and expiratory stridor. Vital signs assessed by the nurse include blood pressure 70/40 mm Hg, heart rate 130 beats/min, and respirations 36/min. What is the priority intervention?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hr following a burn injury?

The client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: T: 95° F and high white blood cell count. What is the priority of care for the patient?

The nurse in trauma unit has received report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care?

A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)

A nurse in the ICU is planning the care of a patient who is being treated for shock. Which of the following statements best describes the pathophysiology of this patient's health problem?

The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patients temperature is newly elevated at 100.2F (37.9C), and the patient exhibits new-onset agitation and confusion. What should the nurse do first?