The nurse receives change-of-shift report on the following four clients in a burn unit. Which client should the nurse assess first?

A client with smoke inhalation who has wheezes and altered mental status

A client with 40% total body surface area (TBSA) burns who is receiving IV fluids at 250 mL/hour

A client with full thickness leg burns who has a dressing change scheduled

A client with abdominal burns who is complaining of level 8 (0 to 10 scale) pain

Answer and Explanation

The Correct Answer is A

Choice A reason: Smoke inhalation with wheezes and altered mental status indicates potential airway compromise and hypoxemia, critical in the ABCDE approach. Wheezing suggests bronchospasm or edema, and altered mental status may reflect cerebral hypoxia or carbon monoxide poisoning, requiring immediate assessment and intervention to secure the airway and restore oxygenation.

Choice B reason: A client with 40% TBSA burns receiving IV fluids at 250 mL/hour is being treated for hypovolemia, a circulation issue in the ABCDE approach. While serious, this client is stable with ongoing treatment. Airway and breathing issues, as in smoke inhalation with altered mental status, take precedence due to rapid lethality.

Choice C reason: Full-thickness leg burns with a scheduled dressing change address infection risk and wound care, which are important but not immediate priorities. The ABCDE approach prioritizes airway and breathing over wound management. Smoke inhalation with neurological changes indicates a more urgent threat to life, requiring assessment before routine procedures.

Choice D reason: Level 8 pain in abdominal burns is significant and requires management, but pain is addressed after airway, breathing, and circulation in the ABCDE approach. Smoke inhalation with wheezes and altered mental status suggests airway compromise and hypoxemia, which are more immediate threats, making pain control a lower priority.

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Correct Answer is C

Explanation

Choice A reason: A respiratory rate of 28/min and temperature of 101°F suggest tachypnea and fever, possibly due to infection or inflammation. While concerning, these do not indicate immediate life-threatening issues like acute coronary syndrome. The ABCDE approach prioritizes circulation (chest pain) over respiratory rate, making this a lower priority.

Choice B reason: Difficulty swallowing and nausea may indicate an esophageal issue or infection but are not immediately life-threatening. These symptoms do not compromise airway, breathing, or circulation acutely in the ABCDE framework. Chest pain with diaphoresis suggests a cardiac emergency, which takes precedence due to potential for rapid deterioration.

Choice C reason: Chest pain with diaphoresis is highly suggestive of acute coronary syndrome, such as myocardial infarction, a life-threatening emergency. The ABCDE approach prioritizes circulation, and these symptoms indicate potential cardiac ischemia, requiring immediate assessment, ECG, and intervention to prevent cardiac arrest, making this the highest priority client.

Choice D reason: Blood pressure of 100/60 mm Hg with a painful, swollen wrist suggests a musculoskeletal injury with mild hypotension. While concerning, it is not immediately life-threatening compared to chest pain with diaphoresis, which may indicate acute coronary syndrome. The ABCDE approach prioritizes circulation issues like cardiac events over stable injuries.

A. Insertion of a tracheostomy with frequent suctioning B. Endotracheal intubation and mechanical ventilation C. Initiation of continuous positive airway pressure (CPAP) D. Administration of 100% O2 by non-rebreather mask

Correct Answer is B

Explanation

Choice A reason: Tracheostomy is used for long-term airway management in chronic respiratory failure or airway obstruction. A respiratory rate of 6 breaths/min and SpO2 of 88% with lethargy indicate acute respiratory failure requiring immediate ventilatory support. Tracheostomy is invasive and time-consuming, making it less suitable than intubation for acute stabilization.

Choice B reason: A respiratory rate of 6 breaths/min, SpO2 of 88%, and increasing lethargy indicate severe hypoventilation and hypoxemia, risking respiratory arrest. Endotracheal intubation with mechanical ventilation ensures airway protection and adequate gas exchange, correcting CO2 retention and hypoxemia. This is the most effective intervention for acute respiratory failure in this critical scenario.

Choice C reason: Continuous positive airway pressure (CPAP) supports breathing in patients with adequate respiratory effort, like in obstructive sleep apnea. A respiratory rate of 6 breaths/min and lethargy suggest inadequate ventilation, requiring controlled mechanical support. CPAP is non-invasive but insufficient for severe hypoventilation, making it inappropriate for this acute situation.

Choice D reason: A non Yvonne-rebreather mask delivering 100% O2 can improve hypoxemia but does not address hypoventilation (respiratory rate 6 breaths/min) or CO2 retention, which contribute to lethargy. Mechanical ventilation via intubation is needed to correct both hypoxemia and hypercapnia, making this a less effective intervention for the client’s critical condition.

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The nurse receives change-of-shift report on the following four clients in a burn unit. Which client should the nurse assess first?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A client with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The client is increasingly lethargic. Which intervention will the nurse anticipate?

Correct Answer is B

Explanation

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