When planning care for a male client with burns on the upper torso, which nursing diagnosis should take the highest priority?
a- Ineffective airway clearance related to edema of the respiratory passages
b- Impaired physical mobility related to the disease process
c- Disturbed sleep pattern related to facility environment
d- Risk for infection related to breaks in the skin
Answer A.
When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity.
Therefore, option A should take the highest priority.
Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate, but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.
a- Ineffective airway clearance related to edema of the respiratory passages
b- Impaired physical mobility related to the disease process
c- Disturbed sleep pattern related to facility environment
d- Risk for infection related to breaks in the skin
Answer A.
When caring for a client with upper torso burns, the nurse’s primary goal is to maintain respiratory integrity.
Therefore, option A should take the highest priority.
Option B isn’t appropriate because burns aren’t a disease. Option C and D may be appropriate, but don’t command a higher priority than option A because they don’t reflect immediately life-threatening problems.