A nurse is caring for a client who has sustained burns over 35% of his total body surface area, including burns to the neck and shoulders. The client's voice has become hoarse, and he has a brassy cough. The nurse should identify these findings as indications that the client has which of the following?

Carbon monoxide poisoning.

Pulmonary edema.

Inhalation injury.

Bacterial pneumonia.

Answer and Explanation

The Correct Answer is J

Choice A reason: Carbon monoxide poisoning occurs when carbon monoxide binds to hemoglobin, preventing oxygen from binding and leading to hypoxia. Symptoms include headache, dizziness, weakness, upset stomach, vomiting, chest pain, and confusion. However, a hoarse voice and a brassy cough are not typical symptoms of carbon monoxide poisoning. These symptoms are more indicative of an inhalation injury due to direct thermal or chemical damage to the airway.

Choice B reason: Pulmonary edema refers to fluid accumulation in the lungs, which can cause difficulty breathing, a feeling of suffocating or drowning, and a cough that produces frothy sputum. Although pulmonary edema can occur after significant burn injuries due to fluid resuscitation or other complications, the specific symptoms of a hoarse voice and brassy cough are more suggestive of an inhalation injury than pulmonary edema.

Choice C reason: An inhalation injury is

The correct answer. This type of injury occurs when a patient inhales smoke, hot gases, or toxic chemicals during a fire. Symptoms can include a hoarse voice, brassy cough, stridor, and respiratory distress. The hoarseness and brassy cough are classic signs of damage to the upper airway due to the inhalation of hot gases or smoke, leading to swelling and irritation of the airway tissues.

Choice D reason: Bacterial pneumonia is an infection of the lungs that can cause symptoms such as fever, chills, cough with phlegm, shortness of breath, and chest pain. While pneumonia can develop as a secondary complication in burn patients, the immediate symptoms of a hoarse voice and brassy cough are more indicative of an inhalation injury rather than bacterial pneumonia.

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Correct Answer is B

Explanation

Choice A reason: Suctioning every 2 hours is not appropriate for a patient with increased intracranial pressure (ICP). Suctioning can increase ICP due to the stress and stimulation it causes. It should only be performed when absolutely necessary and with proper precautions to minimize ICP spikes.

Choice B reason: Providing rest periods between nursing procedures is the correct measure. This helps minimize stimulation and stress, which can increase ICP. Rest periods allow the patient to stabilize and reduce the risk of further increasing the pressure within the skull.

Choice C reason: Encouraging active range of motion exercises is not suitable for a patient with increased ICP. Physical activity can exacerbate the condition by increasing intracranial pressure. The focus should be on minimizing activity and stress to prevent further elevation of ICP.

Choice D reason: Assigning the patient to a semiprivate room near the nurse's station is not the best approach. Patients with increased ICP require a quiet and calm environment to help manage their condition. A semiprivate room near the nurse's station may expose the patient to more noise and activity, which could increase ICP.

A. Place the client in a side-lying position. B. Administer hydromorphone for pain as prescribed. C. Obtain daily weights. D. Maintain a high-calorie, high-protein diet. E. Monitor the client's respiratory status.

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Placing the client in a side-lying position is beneficial for comfort and can help alleviate pain in clients with acute pancreatitis. This position can reduce pressure on the pancreas and improve circulation, helping to manage pain and discomfort effectively.

Choice B reason: Administering hydromorphone for pain as prescribed is essential in managing acute abdominal pain associated with acute pancreatitis. Pain control is a priority in the care of these clients because unmanaged pain can lead to increased stress and further complications. Hydromorphone, a potent opioid analgesic, helps to effectively manage severe pain.

Choice C reason: Obtaining daily weights is important for monitoring a client's nutritional status and fluid balance, but it is not directly related to the immediate management of acute abdominal pain in acute pancreatitis. While it is a relevant intervention, it is not as critical as the other measures listed.

Choice D reason: Maintaining a high-calorie, high-protein diet is not appropriate for a client with acute pancreatitis. In fact, clients with acute pancreatitis are often placed on a nil-per-os (NPO) status initially to rest the pancreas and reduce enzyme secretion. Once the inflammation subsides, a low-fat, bland diet may be introduced gradually.

Choice E reason: Monitoring the client's respiratory status is crucial because clients with acute pancreatitis are at risk for respiratory complications, such as pleural effusion, acute respiratory distress syndrome (ARDS), or atelectasis. Close monitoring ensures early detection and intervention for any respiratory issues that may arise.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of these measures is appropriate for a patient diagnosed with increased intracranial pressure?

Correct Answer is B

Explanation

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

Correct Answer is ["A","B","E"]

Explanation

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for?

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What findings would the nurse expect when caring for a client who is experiencing spinal shock?

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