Care Manager Certification Practice Exam

What is the nurse's priority intervention for a client with deep partial- and full-thickness burns during the resuscitation phase?

1. Initiate fluid resuscitation.

2. Medicate for pain.

3. Insert an indwelling urinary catheter.

4. Maintain the airway.

The correct answer is: Maintain the airway.

In the context of managing a client with deep partial- and full-thickness burns during the resuscitation phase, maintaining the airway is of paramount importance. This is crucial because clients with significant burn injuries are at risk for airway compromise due to potential inhalation injuries, swelling, or smoke inhalation, which can lead to respiratory distress or failure. During the resuscitation phase, the priority is to ensure that the patient can breathe adequately and that the airway remains patent. If the airway is compromised, it can quickly lead to catastrophic outcomes, making it the top priority among interventions. While fluid resuscitation is critical due to the risk of hypovolemia from fluid loss through burned skin, and pain management is essential for comfort, neither of these interventions can take precedence over ensuring a patent airway. The insertion of an indwelling urinary catheter is also important for monitoring urine output and kidney function, but again, it does not address the immediate survival needs related to breathing. Thus, ensuring the safety and patency of the airway takes precedence in the life-threatening context of the resuscitation phase for burn patients.