The nurse is caring for a patient with pulmonary hypertension. The nurse knows that which manifestation is common with this disorder? 

Choice A rationale

Iron is a crucial component of hemoglobin and is essential for erythropoiesis. However, a significant burn injury primarily causes massive fluid shifts and plasma loss from the intravascular space into the interstitial spaces, leading to hypovolemia and hemoconcentration. Iron supplementation would not address the immediate, life-threatening fluid and protein depletion that characterizes the initial phase of a major burn.

Choice B rationale

PRBCs, or packed red blood cells, are used to restore oxygen-carrying capacity in the event of significant blood loss or anemia. While a burn patient may eventually become anemic, the immediate and most critical need following a major burn is the replacement of lost plasma volume and proteins, which is not effectively addressed by PRBCs alone.

Choice C rationale

A severe burn causes a substantial loss of plasma proteins, including albumin, globulins, and clotting factors, from the circulation due to increased capillary permeability. Fresh frozen plasma (FFP) is rich in these proteins and clotting factors, making it the most appropriate choice to restore intravascular volume, oncotic pressure, and hemostasis, thereby combating hypovolemic shock.

Choice D rationale

Albumin is a major plasma protein and is effective for increasing oncotic pressure and drawing fluid back into the vasculature. However, fresh frozen plasma (FFP) is a more comprehensive choice as it contains albumin along with other essential plasma proteins, coagulation factors, and immunoglobulins, which are all depleted following a severe burn injury

Choice A rationale

Increasing the suction pressure would not address the underlying issue of an air leak and could potentially worsen the patient's condition by causing further lung collapse or trauma. Continuous bubbling in the water-seal chamber indicates a persistent air leak from the pleural space, tubing, or at the insertion site, which needs to be identified and resolved. Adjusting the suction without finding the source of the leak is an inappropriate intervention.

Choice B rationale

Clamping the chest tube is a dangerous intervention as it can lead to a tension pneumothorax, a life-threatening condition. Clamping prevents air and fluid from exiting the pleural space, causing pressure to build up and compress the lung, heart, and great vessels. This action should only be performed for very brief periods under specific, controlled circumstances, such as when changing the drainage system.

Choice C rationale

Continuous bubbling in the water-seal chamber is not a normal finding. Normal bubbling in this chamber should only occur intermittently with the patient's respirations, indicating the resolution of the pneumothorax. Continuous bubbling signifies an ongoing air leak, which requires investigation. The nurse must not document this as a normal finding but rather as an abnormal assessment that warrants immediate action.

Choice D rationale

Continuous bubbling in the water-seal chamber indicates a persistent air leak in the pleural space or the drainage system. The nurse must systematically check all connections from the insertion site to the drainage unit to identify and correct the source of the leak. The goal is to ensure the integrity of the closed system to prevent atmospheric air from entering the chest and to facilitate lung re-expansion.