1. A nurse is caring for a client admitted to the emergency department with extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should ... be aware that initially the client is at greatest risk for A. airway obstruction. Rationale: Burns of the head, neck, and chest may involve damage to the pulmonary tree due to heat as well as smoke and soot inhalation. This can result in severe respiratory difficulty. Nursing measures to maintain a patent airway should take priority in this client's care. B. infection. Rationale: Although prevention of infection is an important aspect of burn care throughout hospitalization and treatment, there is a greater initial priority for this client. C. fluid imbalance. Rationale: Although adequate fluid replacement is an important aspect of burn care throughout the acute phase of burn treatment, there is a greater initial priority for this client. D. paralytic ileus. Rationale: Although paralytic ileus may occur during the acute phase aspect of burn care and may require nasogastric suctioning, there is a greater initial priority for this client. [Show More]
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