You have just received the change-of-shift report in the burn unit. Which client requires the most immediate assessment or intervention?
A 22-year-old admitted 4 days previously with facial burns due to a house fire who has been crying since recent visitors left
A 34-year-old who returned from skin-graft surgery 3 hours ago and is complaining of level 8 pain (0-10 pain scale)
A 45-year-old with deep partial-thickness leg burns who has a temperature of 102.6° F and a blood pressure of 98/46
A 57-year-old who was admitted with electrical burns 24 hours ago and has a blood potassium level of 5.0 mEq/L
The Correct Answer is C
Rationale:
A. The 22-year-old who is crying after visitors left is experiencing emotional and psychological distress. While psychosocial support is an important component of burn care, this situation does not represent an immediate threat to life. Emotional needs can be addressed after physiologic priorities are managed.
B. The 34-year-old who recently returned from skin-graft surgery and reports severe pain requires prompt pain management. Uncontrolled pain can cause stress responses and delayed healing, but pain alone, in the presence of stable vital signs, is not immediately life-threatening and does not take priority over signs of systemic instability.
C. The 45-year-old with deep partial-thickness burns, a fever of 102.6°F, and hypotension with a blood pressure of 98/46 is exhibiting signs suggestive of sepsis or early septic shock. Burn patients are highly susceptible to infection due to loss of skin integrity and impaired immune response. The combination of fever and low blood pressure indicates systemic infection with compromised perfusion, which can rapidly progress to multi-organ failure if not treated immediately. This client requires urgent assessment and intervention, including hemodynamic support and evaluation for infection.
D. The 57-year-old with electrical burns and a potassium level of 5.0 mEq/L has a value at the upper limit of normal. Electrical burns increase the risk for hyperkalemia due to muscle damage, so this finding requires close monitoring, but it is not immediately life-threatening at this level and does not take priority over hypotension and fever.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. 3.3 mL would deliver approximately 742 mg, which is far above the prescribed dose.
B. 1.1 mL provides approximately 250 mg, matching the provider’s order.
First, identify the ordered dose and the available concentration.
Ordered dose = 250 mg
Available concentration = 225 mg per 1 mL
Use the medication calculation formula:
Amount to administer (mL) = Ordered dose ÷ Concentration
250 mg ÷ 225 mg/mL = 1.11 mL, which rounds to 1.1 mL
C. 2.5 mL refers to the reconstitution volume, not the amount to administer.
D. 1 mL would deliver only 225 mg, which is less than the prescribed dos
Correct Answer is A
Explanation
Rationale:
A. Hypothermia is correct because rapid infusion of large volumes of crystalloid fluids—especially if the fluids are at room temperature or refrigerated—can lower the patient’s core body temperature. This is particularly important in patients in shock because hypothermia can exacerbate coagulopathy, impair oxygen delivery, and increase the risk of arrhythmias, all of which can worsen outcomes. In addition, critically ill patients are often already at risk for hypothermia due to exposure during resuscitation, impaired thermoregulation, or blood loss. Nursing interventions include monitoring temperature closely, using fluid warmers, applying warming blankets, and assessing for shivering.
B. Bradycardia is incorrect because fluid resuscitation for hypovolemic shock typically increases preload and cardiac output, leading to tachycardia as a compensatory mechanism. Bradycardia is not a common or expected effect of large-volume crystalloid infusion in this context, and if present, it may indicate another problem such as cardiac conduction abnormalities or medication effects.
C. Coffee ground emesis is incorrect because this indicates upper gastrointestinal bleeding, which is not a direct consequence of crystalloid fluid administration. While stress-related mucosal disease can occur in critically ill patients, coffee ground emesis is not an expected sign to monitor specifically due to fluid resuscitation.
D. Pain is incorrect because although a patient may experience discomfort at the IV site or from underlying injuries, pain is not a specific or anticipated effect of large-volume crystalloid infusion. Monitoring for pain is always appropriate, but it is not the priority sign related to this intervention.
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