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","B","E"]

Explanation

A. Raisins: Dried fruits like raisins are concentrated sources of potassium and should be avoided in CKD.

B. Bananas: Bananas are high in potassium and commonly restricted in CKD to prevent hyperkalemia.

C. Green beans: Green beans are relatively low in potassium and generally safe for a renal diet.

D. Asparagus: Asparagus has moderate potassium levels but can be included in moderation depending on the client's labs.

E. Tomatoes: Tomatoes, especially in processed forms like sauce or juice, are high in potassium.

A. Oxygen saturation 93% B. Distended neck veins C. The client has gained 1 pound since yesterday. D. Return of skin to previous position when the client's shin is palpated

Correct Answer is B

Explanation

A. Oxygen saturation 93%:
While this is slightly below normal, it is not a definitive or specific indicator of fluid overload.

B. Distended neck veins:
Jugular vein distention is a classic sign of fluid overload and increased central venous pressure.

C. The client has gained 1 pound since yesterday:
A 1-pound weight gain could be due to fluid retention, but it's not significant enough on its own to confirm fluid overload.

D. Return of skin to previous position when the client's shin is palpated:
This indicates normal skin turgor and does not suggest fluid overload; instead, it rules out dehydration.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client diagnosed with chronic kidney disease (CKD) about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

A nurse is assessing a client diagnosed with end-stage renal disease (ESRD) that is receiving hemodialysis. Which of the following findings should the nurse identify as an indication that the client is experiencing fluid overload?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte Imbalances should the nurse expect?

A nurse is caring for a client admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

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?

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

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?

A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?

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?