a nurse is caring for a patient with a burn injury what is the priority intervention
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ATI Capstone Medical Surgical Assessment 2 Quizlet

1. When caring for a patient with a burn injury, what is the priority intervention?

Correct answer: A

Rationale: The priority intervention when caring for a patient with a burn injury is to monitor the burn area for infection. This is crucial to prevent further complications such as sepsis. While administering IV fluids is important for fluid resuscitation, it is not the top priority compared to preventing infection. Debriding the burn area and applying a dry dressing are necessary interventions for wound care, but ensuring there is no infection takes precedence to avoid sepsis and other serious complications.

2. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

Correct answer: B

Rationale: The correct answer is to monitor the client's skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because while inspecting the pin site is important, it should be done more frequently than every 4 hours. Choice C is incorrect as the halo device should be supported by the client's body weight, not personnel, when repositioning. Choice D is incorrect because applying powder frequently can increase the risk of skin irritation and infection.

3. What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.

4. A nurse misreads a blood glucose level and administers excess insulin. What should the nurse monitor for?

Correct answer: B

Rationale: The correct answer is to monitor for hypoglycemia. Excess insulin can lead to low blood glucose levels, causing hypoglycemia. Symptoms of hypoglycemia include sweating, trembling, dizziness, confusion, and in severe cases, loss of consciousness. Options A, C, and D are incorrect because administering excess insulin would not lead to hyperglycemia or increased thirst, and administering glucose IV would exacerbate the issue by further lowering blood glucose levels.

5. What is the priority action for a patient with chest pain from acute coronary syndrome?

Correct answer: A

Rationale: The correct answer is to administer sublingual nitroglycerin. This medication helps dilate the blood vessels, reducing the workload of the heart and improving blood flow to the heart muscle, which is crucial in the management of acute coronary syndrome. Checking cardiac enzymes (choice B) is important for diagnosing a heart attack but is not the priority over providing immediate relief to the patient's chest pain. Administering aspirin (choice C) is also important in acute coronary syndrome to prevent further clot formation, but it is not the priority action for immediate pain relief. Obtaining IV access (choice D) is necessary for administering medications or fluids; however, in this scenario, providing sublingual nitroglycerin for prompt pain relief takes precedence.

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