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 D

Explanation

A. Urinary output 25 mL/hr: This is below normal, but not an immediate airway threat.

B. Heart rate 122/min: Elevated HR is common in burns due to fluid shifts and stress.

C. Pain of 6 on a scale of 0 to 10: Pain is expected but not life-threatening.

D. Difficulty swallowing secretions: Indicates possible airway edema or inhalation injury, which can progress to airway obstruction. This is a medical emergency.

A. Decreased serum sodium B. Decreased serum phosphorus C. Decreased urine specific gravity D. Decreased serum potassium

Correct Answer is D

Explanation

A. Decreased serum sodium: Kayexalate exchanges sodium for potassium, so sodium may actually increase.

B. Decreased serum phosphorus: Kayexalate does not directly affect phosphate levels.

C. Decreased urine specific gravity: Kayexalate does not influence urine output or concentration.

D. Decreased serum potassium: Kayexalate treats hyperkalemia by exchanging potassium ions for sodium in the intestines, lowering serum potassium.

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

A nurse is caring for a client receiving sodium polystyrene sulfonate (Kayexalate) for the treatment of chronic renal disease. The nurse should monitor for which therapeutic effect of sodium polystyrene sulfonate (Kayexalate)?

Correct Answer is D

Explanation

A client has been admitted to a burn intensive care unit with extensive full thickness burns over 36% of the body. After ensuring cardiopulmonary stability, which should be the nurse's highest priority when planning the client's care in the early acute phase of the injury?

A nurse is caring for a client who has a new arteriovenous (AV) graft in his left forearm. Which of the following techniques should the nurse use to assess the patency of this graft?

A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

A nurse is assessing a client in the oliguric phase of acute kidney injury (AKI). Which of the following findings should the nurse expect?

A nurse is caring for a client post hemodialysis. The nurse assesses bleeding at the AV fistula site, the nurse should prioritize which of the following actions?

A nurse is caring for a client with a burn injury. Which assessment findings by the nurse would indicate a deep partial-thickness burn?

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?