A nurse has admitted a client with burns to the head, face, and hands. On initial assessment, wheezing is noted. On reassessment, the nurse notes decreased bilateral lung sounds. The client appears anxious. respiration rate is 30, and Pulse oximetry is 80%. Which of the following is the priority action the nurse should take?

Encourage the client to cough and auscultate the lungs again.

Document the change and continue to monitor the client's respiratory rate.

Notify the health care provider and prepare for endotracheal intubation.

Reposition the client in high-Fowler's position and reassess breath sounds.

Answer and Explanation

The Correct Answer is C

A. Encourage the client to cough and auscultate the lungs again:
This delays necessary intervention and is not appropriate for suspected airway compromise.

B. Document the change and continue to monitor the client's respiratory rate:
Passive monitoring is not safe here given signs of impending respiratory failure.

C. Notify the health care provider and prepare for endotracheal intubation:
Facial burns and decreasing breath sounds suggest airway edema—immediate intubation is critical before complete airway obstruction.

D. Reposition the client in high-Fowler's position and reassess breath sounds:
While positioning helps breathing, it’s not sufficient or timely enough in a rapidly deteriorating airway.

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

Explanation

A. Ensure NPO status: The client is kept NPO before the biopsy to reduce the risk of aspiration if sedation is used.

B. Administer diphenhydramine (Benadryl) prior to procedure: This is not routine for kidney biopsy unless the client has allergies or specific indications.

C. Obtain coagulation studies: Important to assess for bleeding risk because kidney biopsies have a high bleeding potential.

D. Verify informed consent: This is essential before any invasive procedure.

E. Collect a urine specimen prior to procedure: A pre-procedure urine sample is collected for baseline comparison.

A. Increased appetite B. Elevated serum creatinine levels C. Hyperglycemia D. Increased urine output

Correct Answer is B

Explanation

A. Increased appetite: Not typical in AKI; anorexia is more common.

B. Elevated serum creatinine levels: A hallmark of AKI, indicating reduced kidney filtration capacity.

C. Hyperglycemia: Not a direct indicator of AKI, though may occur in diabetics.

D. Increased urine output: AKI is typically oliguric (low urine output) or anuric in early phases.

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Naxlex Comprehensive Predictor Exams

A nurse is preparing a client for the operating room Exhibits A nurse is planning care for a client who is scheduled to have a kidney biopsy. Which of the following interventions should the nurse include in the plan? (Select all that apply)

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

Explanation

A 65-year-old patient is admitted to the hospital with complaints of decreased urine output, fatigue, and swelling in the legs. Which of the following clinical cues is most indicative of acute kidney injury?

Correct Answer is B

Explanation

A nurse is caring for a client with 45% total body surface area (TBSA) thermal burns. During the emergent, initial phases of burn shock the nurse should closely monitor for which electrolyte imbalance?

A nurse is caring for a client experiencing fatigue secondary to anemia from chronic kidney disease (CKD). How should the nurse respond when the client asks about the cause of the anemia symptoms they are experiencing?

A nurse is conducting an assessment of a client with a severe circumferential burn injury to the forearm. Which of the following assessments should the nurse prioritize? (Select All that Apply.)

A nurse is teaching a client diagnosed with chronic kidney disease (CKD) about limiting foods that are high in potassium. Which of the following foods should the nurse instruct the client to avoid? (Select all that apply.)

A nurse is assessing a client with burns to the face, ears, and eyelids. The nurse should identify which of the following as the priority finding to report to the provider?

A nurse has accepted care of a client with a major burn injury. The burns are 2nd and 3rd degree and estimated at 45% of total body surface area (TBSA). In addressing the pathophysiologic changes resulting from major burns the nurse is aware that the priority intervention for this client is?

A nurse is planning meals for a client diagnosed with chronic kidney disease (CKD). The nurse should recognize that which dietary choices are appropriate for the client?