NCLEX National Council Licensure Examination(NCLEX-RN) NCLEX-RN Question # 2 Topic 1 Discussion
NCLEX-RN Exam Topic 1 Question 2 Discussion:
Question #: 2
Topic #: 1
A client sustained second- and third-degree burns to his face, neck, and upper chest. Which of the following nursing diagnoses would be given the highest priority in the first 8 hours’ postburn?
A.
Fluid volume deficit secondary to alteration in skin integrity
B.
Alteration in comfort secondary to alteration in skin integrity
C.
Alteration in sensation secondary to third-degree burn
D.
Alteration in airway integrity secondary to edema of neck and face, which in turn is secondary to alteration in skin integrity
(A) Fluid deficit is a high priority not only during the first 8 hours postburn, but also during the first 36 hours postburn. (B) Alteration in comfort is a high priority during the entire length of the client’s hospitalization and on discharge. (C) Alteration in sensation is a high priority during the first 48–72 hours postburn. Lack of sensation may be indicative of lack of circulation. (D) Alteration in airway integrity is the highest priority for this client in the first 8 hours postburn. Failure to continually assess this client’s airway status could result in poor ventilation and oxygenation, in addition to an inability to intubate the client secondary to excessive edema formation in the neck.
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