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Zorluk: ZorEstablishing Priorities

The nurse is performing a comprehensive assessment on a client who sustained deep partial-thickness and full-thickness burns to 40% of their total body surface area 12 hours ago. Which of the following clinical findings are priorities that require immediate intervention and provider notification? Select all that apply.

  1. Urine output totaling 25 mL over the past two hoursCevap
  2. New onset of a hoarse voice and a dry, hacking coughCevap
  3. Narrowing pulse pressure with a resting heart rate of 128 beats per minuteCevap
  4. D
    Serum potassium level of 5.1 mEq/L
  5. E
    Client reports severe, continuous pain rated as a 9 on a 0 to 10 scale
  6. F
    Capillary blood glucose level of 145 mg/dL (8.0 mmol/L)

Cevap

The correct findings requiring immediate intervention are: a urine output totaling 25 mL over the past two hours, new onset of a hoarse voice and dry cough, and a narrowing pulse pressure with a heart rate of 128 beats per minute.
The correct selections represent acute, life-threatening complications of severe burns that demand immediate medical action. A total urine output of 25 mL over two hours averages to 12.5 mL/hr, which falls critically below the minimum adult requirement of 30 mL/hr (or 0.5 mL/kg/hr), indicating failed fluid resuscitation and hypoperfusion to the kidneys. A new onset hoarse voice and dry cough are classic indicators of an inhalation injury causing rapid laryngeal edema; this predicts an impending loss of the airway, requiring immediate prophylactic intubation. A narrowing pulse pressure combined with tachycardia is a subtle but critical early indicator of hypovolemic shock, demonstrating compensatory peripheral vasoconstriction as intravascular volume rapidly depletes.

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1
Analyze the client's current clinical context and timeline.
The client is 12 hours post-burn injury (40% TBSA). This places the client in the emergent (resuscitative) phase, characterized by massive fluid shifts from the intravascular space to the interstitial space, creating a high risk for hypovolemic shock and airway edema.
Understanding the timeline of burn pathophysiology is essential to distinguish between expected physiological responses and life-threatening complications.
2
Evaluate each finding against the principles of Airway, Breathing, and Circulation (ABCs).
Hoarseness and a dry cough threaten the airway (A). Narrowing pulse pressure with tachycardia, and a severe drop in urine output (12.5 mL/hr) threaten circulation and indicate impending shock (C).
ABCs represent the most immediate threats to life and dictate the absolute highest priority for provider notification.
3
Identify and filter out expected pathophysiological findings.
A potassium of 5.1 mEq/L (due to cell lysis), a glucose of 145 mg/dL (stress response), and a pain score of 9/10 (exposed nerve endings) are all expected during this phase and are not immediate physiological emergencies.
NCLEX prioritization requires nurses to differentiate between expected disease manifestations and acute, unstable deterioration.

Anahtar Kavram

In the emergent phase of burn care, the nurse must prioritize critical signs of impending airway loss and hypovolemic shock over expected pathophysiological responses like pain, stress-induced hyperglycemia, and cell-lysis-induced hyperkalemia.
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Establishing Priorities

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