Practice Question # 744.
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The nurse is working in the emergency room when a client arrives with severe burns of the left arm, hands, face, and neck. Which action should receive priority?Correct
Answer B is correct.
Rationale: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases is of less priority.Incorrect
Answer B is correct.
Rationale: The client with burns to the neck needs airway assessment and supplemental oxygen, so applying oxygen is the priority. The next action should be to start an IV and medicate for pain, making answers A and C incorrect. Answer D, obtaining blood gases is of less priority.
Burns are caused by a transfer of energy from a heat source to the body. Heat may be transferred through conduction or electromagnetic radiation. Burns are categorized as thermal (which includes electrical burns), radiation, or chemical. Tissue destruction results from coagulation, protein denaturation, or ionization of cellular contents. The skin and the mucosa of the upper airways are the sites of tissue destruction. Deep tissues, including the viscera, can be damaged by electrical burns or through prolonged contact with a heat source. Disruption of the skin can lead to increased fluid loss, infection, hypothermia, scarring, compromised immunity, and changes in function, appearance, and body image.
Burn care must be planned according to the burn depth and local response, the extent of the injury, and the presence of a systemic response. Burn care then proceeds through three phases: emergent/ resuscitative phase, acute/intermediate phase, and rehabilitation phase. Although priorities exist for each of the phases, the phases overlap, and assessment and management of specific problems and complications are not limited to these phases but take place throughout burn care.