For a client with a full-thickness burn and absent radial pulse, the nurse's priority action should be to:

Prepare for the Emergency Triage Exam. Sharpen your skills with flashcards and multiple choice questions, each crafted with hints and explanations. Arm yourself with the knowledge needed to pass with confidence!

In the scenario presented, a full-thickness burn combined with the absence of a radial pulse indicates a significant vascular compromise, potentially due to factors like injury or swelling from the burn. The priority action for the nurse is to communicate the absence of the radial pulse to the physician.

Notifying the physician is crucial because the absence of a pulse suggests that the patient is at risk for further complications, including limb ischemia. This condition can develop rapidly in the setting of significant burns, where swelling and fluid accumulation can compromise blood flow. Early intervention by the physician may be necessary, which could include surgical interventions like fasciotomy to relieve pressure and restore blood flow.

While pain management is essential in burn care, administering morphine would not address the urgent nature of the vascular issue at hand. Similarly, continuing to assess the arm without reporting the loss of the pulse would delay critical intervention, and instructing the client to exercise their fingers isn't appropriate given the compromised circulation; it could exacerbate the situation.

In emergency settings, recognizing and prioritizing the most urgent medical needs is crucial for patient safety and positive outcomes. Reporting the absence of blood flow is a vital step that can lead to timely and life-saving measures.

Subscribe

Get the latest from Examzify

You can unsubscribe at any time. Read our privacy policy