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?
Urinary output 25 mL/hr
Heart rate 122/min
Pain of 6 on a scale of 0 to 10
Difficulty swallowing secretions
The Correct Answer is D
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is C
Explanation
Left arm (entire): 9%
Anterior chest: 18%
Total: 9% + 18% = 27%
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