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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Acute hemolysis: While it is a complication of dialysis, it typically presents with back pain, dark red urine, and hypotension.
B. Disequilibrium syndrome: Caused by rapid removal of urea during dialysis, leading to cerebral edema. Early signs include nausea, headache, restlessness, and confusion.
C. Septic shock: Presents with hypotension, tachycardia, and signs of infection. Not the most likely with nausea and headache alone.
D. Air embolism: Presents with sudden chest pain, dyspnea, and hypotension; not typically with headache and restlessness alone.
Correct Answer is B
Explanation
A. Assessing psychosocial coping:
Important, but not a priority in the early acute phase, when survival is the focus.
B. Adequate fluid resuscitation:
Major burns lead to capillary leakage and hypovolemia. Fluid resuscitation prevents shock and organ failure.
C. Provide nutritional support:
Necessary but becomes more relevant in the later stages after fluid and hemodynamic stability are achieved.
D. Mitigating risk of infection:
Infection control is vital but comes after fluid volume replacement in prioritization.
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