A 32-year-old client with a history of asthma presents to the emergency department in severe respiratory distress. The client is using accessory muscles, is unable to speak in complete sentences, and has an SpO2 of 88% on room air. Peak flow measurement is 25% of predicted. Despite three consecutive nebulizer treatments with albuterol, the client shows minimal improvement. Which finding indicates the client is progressing to status asthmaticus requiring immediate escalation of care?

Respiratory rate increases from 28 to 32 breaths/min

Wheezing becomes louder and more prominent on auscultation

Breath sounds become diminished bilaterally with a silent chest

Client reports feeling slightly less short of breath

Answer and Explanation

The Correct Answer is C

A. An increased respiratory rate indicates worsening distress, but it is a less specific marker of impending respiratory failure compared with silent chest or absent breath sounds.

B. Louder wheezing may indicate bronchospasm, but paradoxically, in severe asthma, as airflow diminishes, wheezing may decrease or disappear, signaling critical airflow obstruction, not improvement.

C. Diminished or absent breath sounds indicate severe airway obstruction with minimal airflow, a hallmark of status asthmaticus. This is a life-threatening sign requiring immediate escalation, such as intubation and advanced airway management.

D. Subjective improvement may be misleading. Patients can feel temporarily better due to increased effort or hyperventilation, but objective findings like silent chest take priority in identifying impending respiratory failure.

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Correct Answer is C

Explanation

A. Facilitates the drainage of secretions from chest cavityis incorrect because the drainage of fluid and air from the pleural space is primarily accomplished by the chest tube itself, not the water seal. The water seal’s role is to maintain a one-way barrier, not actively move fluid.

B. Provides for more effective re-inflation of the lungis incorrect because lung re-expansion depends on removing air or fluid from the pleural space and restoring negative pressure. The water seal indirectly supports this by preventing backflow, but its primary function is not to directly re-inflate the lung.

C. Prevents air from moving back into chest cavityis correct because the water seal acts as a one-way valve. It allows air and fluid to exit the pleural space while preventing air from re-entering the chestduring inspiration. This is critical for maintaining negative intrapleural pressure and supporting lung expansion.

D. Is necessary when suction is added to the drainage systemis incorrect because the water seal functions regardless of whether suction is applied. Suction may be added to enhance drainage, but the water seal’s purpose is independent of suction—it always prevents backflow of air into the pleural space.

A. Acute kidney injury B. Dysrhythmia C. Iceberg effect D. Hypernatremia E. Bone fractures F. Fluid volume overload

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

Explanation

A. Acute kidney injury (AKI)is a common complication of electrical burns due to myoglobin release from muscle damage (rhabdomyolysis). Myoglobin can accumulate in the kidneys, causing renal tubular obstruction and acute tubular necrosis.

B. Dysrhythmiascan occur because electrical currents pass through the body and disrupt cardiac conduction, leading to arrhythmias, which may be life-threatening. Continuous cardiac monitoring is essential.

C. The iceberg effectrefers to the fact that electrical burns often cause deeper tissue injury than is visible on the skin, including muscle, nerve, and bone damage beneath the surface. This hidden injury can lead to complications such as compartment syndrome and rhabdomyolysis.

D. Hypernatremiais not a primary risk in electrical burns. Electrolyte imbalances are more commonly hyponatremia or hyperkalemia, especially during fluid shifts and muscle breakdown.

E. Bone fracturesmay occur if the patient experienced violent muscle contractions during the electrical shock. Electrical currents can cause severe tetanic muscle contractions, which can lead to fractures, especially in older adults with decreased bone density.

F. Fluid volume overloadis not typically a risk immediately after electrical burns. The initial concern is hypovolemia from fluid loss due to capillary leak and tissue injury, requiring aggressive fluid resuscitation. Overload may occur later if fluids are over-administered, but it is not an inherent risk of the burn itself.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a chest tube connected to gravity drainage. Which of the following statements would the nurse identify as the purpose of the water seal?

Correct Answer is C

Explanation

A 65 year old male patient has experienced full-thickness electrical burns on the legs and arms. As the nurse you know this patient is at risk for the following: Select all that apply:

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

Explanation

Which of the following complications is associated with mechanical ventilation? Select all that apply

The nurse is caring for four clients. Which client does the nurse identify at greatest risk of developing acute respiratory distress syndrome (ARDS)?

The nurse is caring for a client diagnosed with septic shock. Which finding would lead the nurse to suspect the client is developing disseminated intravascular coagulation (DIC)?

After morning care, the nurse prepares for tracheostomy care. Which action will the nurse take? Select all that apply.

The nurse is triaging a 65-year-old patient who arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. What category is appropriate?

Exhibits In what order will the nurse implement these interventions?