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Burn NCLEX Questions with Answers and Rationales, Exams of Nursing

Burn NCLEX Questions with Answers and Rationales A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is top priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake

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2024/2025

Available from 12/03/2024

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1. A nurse is caring for a client who has full-thickness burns covering 63% of her body and smoke inhalation. Which of the following nursing actions is top priority? A. Monitor intake and output B. Administer antibiotics C. Monitor respiratory status D. Encourage fluid and food intake Correct Answer is C. Monitor Respiratory Status The priority action for the nurse when using airway, breathing, and circulation (ABC) approach to client care is to monitor the client’s respiratory status closely. Smoke inhalation most likely includes a thermal injury to the tracheobronchial tree. Edema from the inflammatory response to heat can obstruct the airway. Endotracheal intubation may become necessary to maintain a patient airway. Incorrect Answers A. The nurse should monitor the client’s intake and output because clients who have sustained major burns quickly dehydrate as a result of the fluid shift from the vascular system into the interstitial space; however, another action is the priority. B. Infection is serious health risk for clients who sustained major burns, and antibiotic therapy is probable; however, another action is the priority. C. Nutritional support is essential for clients who sustained major burns, although they might receive nutrients via IV or enteral tube initially; another action is the priority