Question

During the emergent phase of burn care, the client is at risk for developing--------Nurses' Notes

1800:
Emergency medical team removed client's shirt at the scene and initiated 18-gauge IV therapy in the right antecubital space.
Client has full-thickness burns over the upper half of the chest and both forearms; partial-thickness burns are present on the client's face and neck.
Sinus tachycardia, pulses to brachial extremities palpable. 1+ edema to upper extremities.
Respirations even, labored with scattered rhonchi. Soot noted to the client's mouth and nose. Oxygen 40% via face tent applied.
Hypoactive bowel sounds.
16 French indwelling urinary catheter inserted with return of 250 mL of yellow urine.
Lactated Ringer's infusing to right antecubital. Provider preparing to insert right femoral central line catheter.
1830:
Client's voice is becoming hoarse and reports difficulty swallowing. Wheezes present to upper lobes bilaterally. Provider notified. Client positioned upright, oxygen via face tent. Blood collected for ABGs. ----------Vital Signs
1800:
Temperature 37.2° C (99° F)
Heart rate 112/min
Respiratory rate 24/min
Blood pressure 136/84 mm Hg
Oxygen saturation 95% via face tent1815:
Option 1: A. Acute Respiratory Distress Syndrome (ARDS)

Option 2: B. Septic Shock

Option 3: C. Hypovolemic Shock

Option 4: D. Hyperkalemia

Answer 1

During the emergent phase of burn care, the client is at risk for developing Acute Respiratory Distress Syndrome (ARDS), which is a life-threatening condition that can occur in severe burn patients.

Step-by-step explanation:

During the emergent phase of burn care, the client is at risk for developing Acute Respiratory Distress Syndrome (ARDS).

ARDS is a life-threatening condition that can occur in severe burn patients due to the loss of protection by intact layers of skin, making the burned skin extremely susceptible to bacteria and other pathogens. This can lead to an infection and subsequent inflammation in the lungs, causing respiratory distress.

In this case, the patient's symptoms, such as difficulty swallowing, wheezing, and labored breathing, along with the presence of soot in the mouth and nose, are indicative of ARDS.