A nurse is assessing a client with a burn injury. The client is experiencing hoarseness, a brassy cough, and drooling. The nurse recognizes these findings as indicative of which of the following?

Carbon monoxide poisoning

Pulmonary edema

Bacterial pneumonia

Inhalation injury

Answer and Explanation

The Correct Answer is D

A. Carbon monoxide poisoning: This condition often presents with symptoms such as headache, dizziness, nausea, and confusion. It does not typically cause hoarseness, drooling, or a brassy cough, which are signs of upper airway irritation or obstruction.

B. Pulmonary edema: While it causes respiratory distress and crackles, it is characterized more by dyspnea, frothy sputum, and hypoxia than by hoarseness or brassy cough. Drooling is also not a usual feature of pulmonary edema.

C. Bacterial pneumonia: Pneumonia generally presents with fever, productive cough, and adventitious breath sounds. It does not commonly cause hoarseness or drooling, which suggest upper airway involvement rather than lower respiratory infection.

D. Inhalation injury: Hoarseness, brassy cough, and drooling indicate thermal or chemical injury to the upper airway. These signs are critical warnings of possible airway obstruction due to laryngeal edema and irritation of the trachea and bronchi and require immediate evaluation and intervention.

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Correct Answer is C

Explanation

A. Hyperkalemia: Elevated potassium levels can occur in ESRD and may cause cardiac dysrhythmias or muscle weakness, but they do not typically cause lung crackles, peripheral edema, or shortness of breath.

B. Hypoxemia: Low oxygen levels may lead to shortness of breath, but they are a symptom rather than a cause in this scenario. The presence of fluid overload signs suggests a more specific underlying issue.

C. Hypervolemia: Fluid overload is common in ESRD due to reduced kidney function. Symptoms such as crackles, peripheral edema, hypertension, and dyspnea point to excess intravascular volume.

D. Hypovolemia: Presents with symptoms such as decreased blood pressure, increased heart rate, poor skin turgor, and dry mucous membranes. The client's elevated blood pressure and lower extremity swelling are contradictory to the signs and symptoms of hypovolemia.

A. Assessing white blood cell count B. Assessing the electrolyte levels C. Reviewing liver function tests D. Checking the red blood cell count

Correct Answer is B

Explanation

A. Assessing white blood cell count: While important for monitoring infection, WBC changes are not the most immediate concern during the early phase of major burns. Infection risk becomes more critical later in the course.

B. Assessing the electrolyte levels: Burns covering 30% TBSA cause massive fluid and electrolyte shifts, especially sodium and potassium imbalances. These changes can lead to cardiac arrhythmias, shock, and organ dysfunction, making this the top priority.

C. Reviewing liver function tests: Liver function may be affected in severe burns, but this is not an early or primary concern. It is monitored more for metabolic function or drug metabolism later in treatment.

D. Checking the red blood cell count: Hematocrit may rise initially due to hemoconcentration, but fluid and electrolyte disturbances have more immediate, life-threatening consequences in the acute phase.

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A nurse is assessing a client with a burn injury. The client is experiencing hoarseness, a brassy cough, and drooling. The nurse recognizes these findings as indicative of which of the following?

Nursing Test Bank

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Correct Answer is C

Explanation

A nurse is reviewing the labs on a client with 30% TBSA burns. What is the nurse's priority when interpreting the lab results?

Correct Answer is B

Explanation

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