A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

Allow the client to suck on small quantities of ice chips.

Apply oxygen and continuous pulse oximetry.

Have the respiratory therapist provide humidified room air.

Request an antitussive medication from the physician.

Answer and Explanation

The Correct Answer is B

A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.

B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.

C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.

D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.

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Correct Answer is B

Explanation

A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.

B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.

C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.

D. Having the water turned on does not pose a significant risk for infection or sepsis.

A. Increase IV fluid infusion per protocol. B. Lower the head of the clients bed in Trendelenburg position C. Document CVP and continue to monitor. D. Administer IV diuretic medications.

Correct Answer is D

Explanation

A. Increasing IV fluids would exacerbate the client's fluid overload and worsen heart failure symptoms.

B. Trendelenburg positioning is typically used for shock management, but this client’s fluid overload needs to be addressed first.

C. Monitoring is important but does not address the immediate need to manage fluid overload.

D. The client's elevated CVP, PAWP, and BNP levels indicate fluid overload and heart failure with reduced ejection fraction. The priority is to reduce fluid overload by administering IV diuretics, which will help reduce the pressure in the heart and lungs, improving oxygenation and decreasing the risk of pulmonary edema.

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A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

Correct Answer is D

Explanation

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