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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Metformin: When combined with contrast dye, it can increase the risk of lactic acidosis in patients with impaired kidney function; should be held before and after contrast use.

B. Atorvastatin: Though statins are metabolized hepatically, they don’t interact significantly with contrast to increase AKI risk.

C. Carvedilol: Beta-blockers do not interact with contrast dye to cause AKI.

D. Nitroglycerin: Used for angina; not associated with increased AKI risk related to contrast use.

A. Urinary output 25 mL/hr B. Heart rate 122/min C. Pain of 6 on a scale of 0 to 10 D. Difficulty swallowing secretions

Correct Answer is D

Explanation

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

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Naxlex Comprehensive Predictor Exams

A nurse is collecting a medication history from a client who is scheduled to have a cardiac catheterization. The nurse should recognize that which of the following medications taken by the client interacts with contrast material, and places the client at risk for acute kidney injury (AKI)?

Correct Answer is A

Explanation

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

Correct Answer is D

Explanation

A nurse in an emergency room is caring for a client who sustained deep partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

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.)

A nurse is monitoring the fluid replacement of a client who has sustained burns over 40% total body surface area (TBSA). The client weight is 100kg According to the Parkland Formula, how much fluid will the client require in the first 8 hours?

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

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 caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

A client who is in the acute phase of recovery from a burn injury has yet to experience adequate pain control. The nurse recognizes that which pain management strategy should best meet this client's pain control needs?