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 B

Explanation

A. Certain antihistamines can worsen urinary retention in BPH, so informing the allergist is a good practice.

B. Alcohol, including wine, can worsen the symptoms of BPH by increasing urinary retention and bladder discomfort. The client needs further teaching regarding the effects of alcohol on BPH symptoms.

C. It is advisable to avoid large volumes of fluids in the morning, as this can exacerbate BPH symptoms.

D. Caffeine can irritate the bladder and worsen BPH symptoms, so weaning off coffee is a helpful measure.

A. Administer multiple vitamins and minerals in the IV solution. B. Infuse total parenteral nutrition via a central catheter. C. Encourage an oral intake of at least 3000 kcal per day. D. Insert a feeding tube and initiate enteral feedings.

Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

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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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Correct Answer is B

Explanation

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Correct Answer is D

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