A nurse has admitted a client with burns to the head, face, and hands. On initial assessment, wheezing is noted. On reassessment, the nurse notes decreased bilateral lung sounds. The client appears anxious. respiration rate is 30, and Pulse oximetry is 80%. Which of the following is the priority action the nurse should take?

Encourage the client to cough and auscultate the lungs again.

Document the change and continue to monitor the client's respiratory rate.

Notify the health care provider and prepare for endotracheal intubation.

Reposition the client in high-Fowler's position and reassess breath sounds.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Muscle layers: Full-thickness burns may extend into muscle, especially with chemical burns.

B. Epidermal layers: The outermost layer is completely destroyed in full-thickness burns.

C. Dermal layers: Full-thickness burns extend through both the epidermis and dermis.

D. Subcutaneous layers: These burns also involve the subcutaneous fat and connective tissue.

E. Bone and ligaments: Involvement of bone and ligaments would indicate a 4th-degree burn, not 3rd-degree.

A. Encourage the client to cough and auscultate the lungs again. B. Document the change and continue to monitor the client's respiratory rate. C. Notify the health care provider and prepare for endotracheal intubation. D. Reposition the client in high-Fowler's position and reassess breath sounds.

Correct Answer is C

Explanation

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing to care for a client after a full thickness chemical burn of the bilateral lower extremities. The nurse is aware that 3rd degree, full thickness burns affect which of the following? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

Correct Answer is C

Explanation

A nurse is assessing a client diagnosed with chronic renal disease for fluid volume excess. The nurse should recognize that which of the following provides a reliable measure of fluid retention?

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

A nurse is assessing a client who has sustained burns on the entire left arm and the anterior chest. Using the rule of nines, the nurse calculates what percentage of total body surface area is affected by the burns?

A nurse is assessing a client who has an electrical burn. Which of the following cues should the nurse recognize as indicating a potential complication of the burn injury?

A child has presented to the ER after a burn injury from a hot soup spill. Exhibits A nurse is caring for a preschooler diagnosed with a superficial partial- thickness burn on the right forearm. Which of the following findings should the nurse expect? (Select all that apply.)