The nurse on a burn unit has just received a change-of-shift report about these clients. Which client does the nurse assess first?
An electrician who suffered external burn injuries a month ago and is asking the nurse to contact the healthcare provider immediately about discharge plans.
Older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body who is receiving IV fluids at 250 mL/hr.
Adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain.
Firefighter with smoke inhalation and facial burns who has just arrived on the unit.
The Correct Answer is D
Choice A reason: The electrician who suffered external burn injuries a month ago is stable enough to be concerned with discharge plans. This indicates that his burns have been managed and he is in a phase of recovery where he is preparing for discharge. Although his request is important, it is not an immediate priority compared to more acute conditions.
Choice B reason: The older adult client admitted yesterday with partial- and full-thickness burns over 40% of the body is in a critical condition and needs continuous monitoring, especially with high fluid administration. However, their condition is currently being managed with IV fluids. While this client requires close observation, there is no immediate indication of a life-threatening change that demands immediate intervention compared to the firefighter's situation.
Choice C reason: The adult client admitted a week ago with deep partial-thickness burns over 35% of the body who is reporting pain is also in need of pain management and ongoing care. However, pain, while significant and requiring treatment, does not take precedence over the potential airway compromise and respiratory distress posed by smoke inhalation and facial burns in the firefighter.
Choice D reason: The firefighter with smoke inhalation and facial burns who has just arrived on the unit must be assessed first due to the immediate risk of airway compromise and respiratory distress. Smoke inhalation can lead to rapid swelling of the airways, making it a critical emergency. Facial burns also increase the risk of airway obstruction. Prompt assessment and intervention are essential to ensure the firefighter's airway remains patent and to provide necessary respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Carbon monoxide poisoning can cause the skin, particularly the face, to appear cherry-red. This occurs because carbon monoxide binds with hemoglobin in the blood, forming carboxyhemoglobin, which gives the skin this distinct color. It is a critical condition that requires immediate intervention as carbon monoxide displaces oxygen in the blood, leading to hypoxia and potentially life-threatening complications.
Choice B reason: Smoke inhalation is a common issue in burn victims and can cause respiratory distress, coughing, and airway irritation. However, it does not typically cause the face to turn a cherry-red color. The primary concerns with smoke inhalation are airway obstruction and lung damage rather than changes in skin color.
Choice C reason: Uremic poisoning, or uremia, results from severe kidney dysfunction and the accumulation of waste products in the blood. Symptoms can include fatigue, confusion, and a metallic taste in the mouth, but it does not cause a cherry-red discoloration of the face.
Choice D reason: Acute anemic hypertension is not a recognized medical condition. Anemia can cause pallor or a pale appearance of the skin, while hypertension typically does not cause skin discoloration. Therefore, this choice is not relevant to the described symptoms.
Correct Answer is A
Explanation
Choice A reason: Monitoring amylase and lipase levels is the best way to determine the effectiveness of treatment in a patient with pancreatitis. These enzymes are produced by the pancreas, and their levels in the blood increase significantly during an episode of pancreatitis. As treatment progresses and the inflammation of the pancreas decreases, the levels of these enzymes should return to normal. Therefore, checking the levels of amylase and lipase is a direct indicator of the patient's response to treatment.
Choice B reason: Hematocrit and hemoglobin levels are important for assessing overall blood volume and oxygen-carrying capacity, but they are not specific indicators of pancreatitis treatment effectiveness. While these levels can provide information about the patient's general health and hydration status, they do not specifically reflect changes in pancreatic inflammation.
Choice C reason: Red blood cell count is another measure of the blood's oxygen-carrying capacity and overall health, but like hematocrit and hemoglobin, it is not specific to pancreatitis. Changes in red blood cell count can occur due to various factors, but they do not provide direct information about the effectiveness of pancreatitis treatment.
Choice D reason: Serum uric acid levels are typically monitored in conditions such as gout or kidney stones, and they are not related to pancreatitis. Monitoring serum uric acid would not provide useful information about the patient's response to pancreatitis treatment.
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