When prioritizing care for a patient with burn injuries, which intervention should be considered first?

Providing wound care.

Assessing skin condition.

Initiating nutritional support.

Ensuring a patent airway.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Providing wound care is an essential component of burn management to prevent infection and promote healing, but it is not the first priority. During the initial resuscitation phase of a burn injury, systemic stability takes precedence over local wound treatment. Once the patient's airway, breathing, and circulation are stabilized, the nurse can then focus on debridement, topical antibiotics, and dressing applications. Addressing the wound first while the airway is compromised could lead to a fatal outcome.

Choice B rationale

Assessing the skin condition is part of the initial head-to-toe survey and helps determine the total body surface area burned using the Rule of Nines. However, this assessment is secondary to life-saving measures. While knowing the extent of the burn is crucial for calculating fluid resuscitation needs, it does not supersede the immediate need to ensure that the patient can breathe. Physiologic stability must be established before detailed mapping of the cutaneous injuries is performed by the team.

Choice C rationale

Initiating nutritional support is a critical long-term intervention for burn patients because they enter a hypermetabolic state that requires significant caloric and protein intake for tissue repair. However, nutritional needs are addressed in the days following the injury, not in the first minutes or hours. Immediate life-threats must be managed before metabolic demands are considered. Providing high-protein and high-calorie nutrition is vital for recovery, but it is not the highest priority during the acute emergency.

Choice D rationale

Ensuring a patent airway is the absolute first priority in the care of a patient with burn injuries, particularly if there is a risk of inhalation injury. Thermal or chemical burns can cause rapid edema of the upper airway, leading to total obstruction and respiratory failure. In any emergency situation, the ABC sequence dictates that the airway must be secured first. Without a functional airway, all other interventions, including fluid resuscitation and wound care, will be ineffective in saving the patient.

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Correct Answer is C

Explanation

Choice A rationale

Providing baths with antiseptic soap is important for reducing the bacterial load on the skin and preventing wound infection, which is a major complication in burn patients. However, excessive bathing can sometimes lead to chilling or further tissue irritation if the soap is too harsh. While infection control is a pillar of burn management, the systemic physiological demands for tissue regeneration are more effectively met through metabolic and nutritional support than through topical cleansing alone.

Choice B rationale

Administering antipyretics is indicated if the patient develops a fever, which is common during the hypermetabolic state following a severe burn. A normal body temperature is approximately 98.6 degrees Fahrenheit. While managing fever can reduce oxygen consumption and patient discomfort, it does not directly promote the healing of the damaged integument. Antipyretics are a symptomatic treatment rather than a primary intervention for the complex biological process of skin grafting and wound closure.

Choice C rationale

Severe burns trigger a profound hypermetabolic and catabolic response that significantly increases the body's demand for energy and protein. Initiating high-calorie, high-protein nutrition is the priority to prevent muscle wasting and provide the building blocks necessary for collagen synthesis and epithelialization. Without adequate caloric intake, the body enters a negative nitrogen balance, which severely delays wound healing and impairs the immune system's ability to fight off potential opportunistic infections.

Choice D rationale

Encouraging daily physical activity and range of motion exercises is vital for preventing contractures and maintaining joint mobility, especially when burns occur over flexor surfaces. However, physical activity is a rehabilitative goal that follows the initial stabilization and acute healing phases. During the early stages of severe burn injury, the physiological priority is meeting the extreme metabolic needs of the body to ensure that there is enough cellular energy to support tissue repair.

A. When moving an object to one side, the client puts his weight on his heels. B. The client stands with his feet close together when lifting an object. C. The client faces the direction of movement when sliding an object across the floor. D. When pushing an object, the client moves his front foot backward.

Correct Answer is C

Explanation

Choice A rationale

Shifting weight to the heels when moving an object to the side is an incorrect application of body mechanics. Proper technique involves pivoting the entire body as a single unit rather than twisting the lumbar spine. Putting weight on the heels can lead to instability and loss of balance during the transition. The client should instead focus on a broad base of support and smooth weight shifts to avoid straining the lower back muscles.

Choice B rationale

Standing with the feet close together during a lift significantly narrows the base of support. This reduces the stability of the center of gravity and increases the risk of falling or causing a musculoskeletal injury to the back. For safe lifting, the feet should be shoulder-width apart to provide a stable foundation. This positioning allows the larger leg muscles, such as the gluteals and quadriceps, to bear the load rather than the vulnerable spinal discs.

Choice C rationale

Facing the direction of movement when sliding or moving an object is a fundamental principle of proper body mechanics. This alignment prevents rotational or twisting forces on the spine, which are primary causes of acute and chronic back injuries. By keeping the shoulders and hips square to the object, the client maintains the natural curvature of the spine. This finding indicates the client successfully understands how to protect the back while performing activities of daily living.

Choice D rationale

Moving the front foot backward when pushing an object is counterproductive to generating force and maintaining balance. To push effectively, a person should move the rear foot forward or lean into the object using their body weight. This stance ensures that the force is generated by the legs and transferred through the core. Reversing the foot movement compromises the stability of the posture and places unnecessary stress on the lower back and shoulder joints.

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When prioritizing care for a patient with burn injuries, which intervention should be considered first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When planning care for a patient with severe burn injuries, what intervention should the nurse prioritize to promote healing?

Correct Answer is C

Explanation

A nurse is collecting data from a client at a follow-up clinic visit for acute low back pain. A goal for this client is to use proper body mechanics at all times. Which of the following findings indicates that the client is meeting this goal?

Correct Answer is C

Explanation

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