NCLEX Med Surg Burns Practice Test 2025 – Comprehensive Exam Prep

Question: 1 / 400

In the acute phase of burn care, what should the nurse prioritize in the care of the patient?

Begin IV fluid replacement.

Monitor for signs of complications.

During the acute phase of burn care, prioritizing monitoring for signs of complications is essential because this phase involves significant physiological changes and potential adverse events due to the severity of the burn injury. Complications can arise from various sources, including infection, hypovolemic shock, electrolyte imbalances, and pulmonary issues, especially with extensive burns. Vigilant monitoring allows for early identification of these complications, which is critical in preventing further deterioration of the patient's condition.

Effective management during this phase requires that the nurse maintain a high level of observation for changes in vital signs, wound conditions, fluid status, and other indicators of complications. Early recognition and intervention can significantly impact patient outcomes and promote healing.

While starting IV fluid replacement and managing pain and anxiety are crucial components of care, they come secondary to the immediate need for close monitoring to detect any complications that may arise due to the body's response to significant injury. Discussing reconstructive surgery would also be inappropriate during this acute phase, as it typically requires stabilization of the patient and a later focus on long-term recovery.

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Assess and manage pain and anxiety.

Discuss possible reconstructive surgery.

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