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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?

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.

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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Related Questions

Correct Answer is []

Explanation

Potential Condition: Urinary Tract Infection (UTI)
The client is reporting frequency, burning, and urgency, classic symptoms of a lower UTI (cystitis). The recent removal of the urinary catheter (which increases infection risk) further supports this.

Actions to take:

  1. Check a urine culture and sensitivity: A urine culture will confirm the presence of infection and identify the specific organism, allowing for appropriate antibiotic selection.
  2. Request a prescription for an antispasmodic agent: Bladder spasms can contribute to frequency and urgency, especially post-catheter removal. An antispasmodic (e.g., oxybutynin) may help relieve discomfort.

Parameters to monitor:

  1. Temperature: Fever can indicate progression of the UTI to pyelonephritis or worsening infection. The current low-grade fever of 100.4°F may be an early sign.
  2. Fluid intake: Adequate hydration helps flush bacteria from the urinary tract and is essential in promoting recovery from a UTI.

Incorrect diagnoses:

The post-void residual is only 22 mL, which rules out urinary retention. No evidence points to STIs like gonorrhea, nor to incontinence.

Correct Answer is C

Explanation

A. Omeprazole: Not directly nephrotoxic, but long-term use has been associated with interstitial nephritis, although rarely.

B. Ondansetron: Generally safe in renal disease and not known to cause nephrotoxicity.

C. Vancomycin: Known nephrotoxic agent, especially with high trough levels or when used with other nephrotoxins; requires dose adjustment in CKD.

D. Diphenhydramine: Not nephrotoxic; primarily affects the CNS and anticholinergic systems.

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