A client is admitted to the burn unit with burns to the upper body and head after a garage fire. Initially wheezes are heard but an hour later the lung sounds are very decreased and no wheezes are audible. What is the best action for the nurse to take?
Reposition the client in high-Fowler's position and reassess breath sounds.
Encourage the client to cough and auscultate the lungs again.
Notify the health care provider and prepare for endotracheal intubation.
Document the results and continue to monitor the client's respiratory rate.
The Correct Answer is C
A. Reposition the client in high-Fowler's position and reassess breath sounds: While positioning can improve ventilation, the absence of previously heard wheezes suggests worsening airway obstruction. Simple repositioning is unlikely to relieve a rapidly progressing airway compromise caused by inhalation injury.
B. Encourage the client to cough and auscultate the lungs again: Coughing may help clear secretions in some situations, but in the context of inhalation injury with decreasing breath sounds, the client is at high risk for complete airway obstruction. Encouraging cough does not address the imminent threat to airway patency.
C. Notify the health care provider and prepare for endotracheal intubation: Diminished or absent breath sounds after initial wheezing indicate progressive airway edema and potential obstruction. Early recognition and preparation for intubation are critical to secure the airway before it becomes impossible to manage. Immediate action is essential to prevent respiratory failure.
D. Document the results and continue to monitor the client's respiratory rate: Simply documenting and monitoring delays urgent intervention and places the client at high risk for complete airway obstruction. This passive approach does not address the acute airway emergency and could result in life-threatening hypoxia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Blood pressure 130/72, pulse 90, respirations 32: These values show mild changes from baseline and could reflect pain, anxiety, or mild physiological response. They are not immediately indicative of increased intracranial pressure.
B. Blood pressure 110/70, pulse 120, respirations 30: This pattern shows hypotension with compensatory tachycardia and mild tachypnea. While concerning, it may reflect hypovolemia rather than acute neurological deterioration.
C. Blood pressure 156/60, pulse 58, respirations 12: This represents Cushing’s triad—hypertension with widened pulse pressure, bradycardia, and irregular or slowed respirations—which is a classic sign of increased intracranial pressure and impending brain herniation. This is a neurological emergency requiring immediate intervention.
D. Blood pressure 148/78, pulse 112, respirations 28: These are elevated but less concerning than the pattern seen in option C. This may indicate pain, stress, or mild ICP increase but is not immediately life-threatening.
Correct Answer is B
Explanation
A. distended neck veins, widening pulse pressure, drop in cardiac output: Cardiac tamponade typically causes narrowing, not widening, of the pulse pressure due to equalization of diastolic pressures and reduced stroke volume.
B. drop in cardiac output, narrowing pulse pressure, jugular vein distension: These are classic signs of cardiac tamponade. Accumulation of fluid in the pericardial sac restricts ventricular filling, decreasing stroke volume and cardiac output, narrowing pulse pressure, and causing venous congestion visible as jugular vein distension.
C. bradycardia, hypotension, narrowing pulse pressure: Hypotension and narrowed pulse pressure are relevant, but bradycardia is not a typical early sign; tachycardia is more common as a compensatory response to reduced cardiac output.
D. hypotension, diminished breath sounds, jugular vein distention: Hypotension and jugular vein distension occur, but diminished breath sounds are more associated with pleural effusion or pneumothorax, not cardiac tamponade.
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