Safety and Infection Control NCLEX Part #2

A child has third-degree burns of the hands, face, and chest. Which nursing diagnosis takes priority? • A. Impaired urinary elimination related to fluid loss • B. Ineffective airway clearance related to edema • C. Disturbed body image related to physical appearance • D. Risk for infection related to epidermal disruption Correct Answer: B. Ineffective airway clearance related to edema Initially, when a preschool client is admitted to the hospital for burns, the primary focus is on assessing and managing an effective airway. Immediately assess the patient’s airway, breathing, and circulation. Be especially alert for signs of smoke inhalation, and pulmonary damage: singed nasal hairs, mucosal burns, voice changes, coughing, wheezing, soot in the mouth or nose, and darkened sputum. Exposure to materials burn can cause inhalation injury. • Option A: Acute renal failure is one of the major complications of burns and it is accompanied by a high mortality rate. Most renal failures occur either immediately after the injury or at a later period when sepsis develops. Late-onset renal failure is usually the consequence of sepsis and is often associated with other organ failure. • Option C: Burn injuries are among the most serious causes of radical changes in body image. The subject of body image and self-image is essential in rehabilitation, and the nurse must be aware of the issues related to these concepts and take them seriously into account in drafting out the nursing programme. • Option D: Invasive infection of burn wounds is a surgical emergency because of the high concentrations of bacteria (105 CFU) in the wound and surrounding area, together with new areas of necrosis in unburned tissues. This situation often is accompanied by signs of sepsis and changes in the burn wound such as black, blue, or brown discoloration of the eschar.