Andrea, a clinical nurse specialist, is caring for a patient who sustained serious facial and neck burns. To which nursing diagnosis would Andrea give first priority in caring for this patient?
  1. Body image disturbance
  2. Fluid volume deficit
  3. Ineffective airway clearance
  4. Ineffective thermoregulation
Explanation
Answer - C - The nursing diagnosis that Andrea would give first priority in caring for this patient is ineffective airway clearance. A patient with facial and neck burns is at high risk for ineffective airway clearance related to possible upper airway edema, secondary to inhalation of superheated air, smoke, or noxious chemicals.
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