A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

Allow the client to suck on small quantities of ice chips.

Apply oxygen and continuous pulse oximetry.

Have the respiratory therapist provide humidified room air.

Request an antitussive medication from the physician.

Answer and Explanation

The Correct Answer is B

A. Sucking on small quantities of ice chips is not appropriate in this case as it may worsen the airway obstruction or cause further irritation.

B. Applying oxygen and continuously monitoring the client's pulse oximetry will help ensure that the client's oxygen saturation remains adequate and that they do not experience respiratory distress or hypoxemia due to inhalation injury. Early intervention is crucial to prevent worsening of respiratory status.

C. Humidified room air can help in cases of airway irritation, but the priority is to ensure oxygenation and avoid hypoxia.

D. Antitussive medications may be indicated later, but airway management and oxygenation take precedence.

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Correct Answer is A

Explanation

A. "I will make sure that my partner takes all the prescribed medication.": This is the correct answer. Expedited partner therapy involves treating the partner(s) without an initial clinical visit, so ensuring they take all prescribed medications is essential to prevent reinfection.

B. "I will have my partner take the antibiotics if any STI symptoms occur.": This is incorrect because the partner should take the antibiotics regardless of symptoms to effectively treat the infection.

C. "I will have my partner use a condom until I finish the antibiotics.": While condom use is important, it does not replace the need for the partner to receive treatment.

D. "I will tell my partner that it is important to be examined at the clinic.": Although important, expedited partner therapy aims to provide treatment without a clinic visit.

A. Assess the client's respiratory status. B. Ask the client about current medications. C. Administer intravenous furosemide. D. Draw blood to assess the client's serum electrolytes.

Correct Answer is A

Explanation

A. Assessing respiratory status is the priority in heart failure exacerbation, as respiratory distress can rapidly worsen and affect oxygenation.

B. While knowing current medications is important, the priority in this situation is addressing the client's respiratory needs.

C. Administering furosemide is part of the management plan but should follow the initial assessment of the client's condition, especially respiratory status.

D. Drawing blood is helpful but not the immediate priority in managing acute heart failure exacerbation.

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Test Name	Results	Reference Range
WBC	12, 000	4, 000- 11, 000
Na+	149 mEq/L	135-145 mEq/L
K+	5.0 mEq/L	3.5- 5.0 mEq/L
Cl-	110 mEq/L	96-106 mEq/L
pH	7.34	7.35-7.45
PaCO2	34 mmHg	35- 45 mmHg
PaO2	78 mm Hg	80-100 mmHg
HCO3	21 mEq/L	22- 26 mEq/L

A client is in the emergency department after being rescued from a house fire. After the initial assessment, the client develops a loud, brassy cough. What intervention by the nurse takes priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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