A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?
Difficulty swallowing
Urinary output 25 mL/hr
Heart rate 122/min
Pain of 6 on a scale of 0 to 10
The Correct Answer is A
Difficulty swallowing is the priority finding to report to the provider. Rationale: This is because difficulty swallowing can indicate airway edema, which can compromise breathing and oxygenation. The nurse should monitor the client's respiratory status and administer oxygen as prescribed. The other findings are also important, but not as urgent as airway obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choiceC. “I will follow a daily diet high in calories and protein.”
Choice A rationale:
Inhaling slowly through pursed lips is incorrect.The correct technique is toexhaleslowly through pursed lips, which helps to keep the airways open longer, allowing for better air exchange and reducing shortness of breath.
Choice B rationale:
Lying on the stomach to practice abdominal breathing is not a recommended strategy for managing emphysema.Abdominal or diaphragmatic breathing can be beneficial, but it is typically practiced in a comfortable, upright position.
Choice C rationale:
Following a daily diet high in calories and protein is correct. People with emphysema often have increased energy needs due to the effort required for breathing.A high-calorie, high-protein diet helps maintain muscle mass and overall health.
Choice D rationale:
Avoiding a flu shot is incorrect.Patients with emphysema are at higher risk for respiratory infections, and getting an annual flu shot is crucial to prevent complications.
Correct Answer is C
Explanation
This is because inhalation injuries can compromise the airway and cause respiratory distress or failure, which can be life-threatening. The nurse should assess for signs such as soot, burns, hoarseness, or stridor.
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