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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D","E"]
Explanation
Choice A reason: Not needing vascular access to perform PD is a significant advantage for patients. Peritoneal dialysis uses the peritoneal membrane in the abdomen as a filter to clean the blood, which eliminates the need for vascular access, such as fistulas or catheters required in hemodialysis. This can reduce the risks associated with vascular access, such as infections and complications related to surgical procedures.
Choice B reason: Being able to perform PD in the comfort of one's home is a major benefit. Patients can manage their dialysis treatments at home, which offers more convenience and flexibility compared to traveling to a dialysis center for hemodialysis sessions. This can greatly improve the quality of life and reduce the burden of frequent trips to healthcare facilities.
Choice C reason: Stating that there is no risk for infection with PD is inaccurate. While PD offers many benefits, it does carry a risk of peritonitis, an infection of the peritoneal cavity. Patients must be educated on proper technique and hygiene to minimize this risk. Hence, this statement is not accurate and should not be included as an advantage.
Choice D reason: Having flexibility in when to do the exchanges is another benefit of PD. Patients can schedule their dialysis exchanges at times that best fit their lifestyle and daily routines. This flexibility allows for greater independence and freedom compared to the fixed schedules required for in-center hemodialysis.
Choice E reason: PD can take less time than hemodialysis treatments, especially when considering travel and waiting times associated with in-center hemodialysis. Although the actual dialysis process for PD requires regular exchanges throughout the day or night, it integrates more seamlessly into daily life, making it a time-efficient option for many patients.
Correct Answer is D
Explanation
Choice A reason: Suctioning the patient immediately is not the appropriate intervention in this context. Suctioning can be necessary if the patient has secretions obstructing the airway, but it does not address the issues of bradycardia (low heart rate) and hypotension (low blood pressure) which are critical in a spinal cord injury.
Choice B reason: Administering normal saline (NS) at 25 cc/hr is not sufficient to address the patient's hypotension. In a patient with a spinal cord injury at the T5 level, hypotension is likely due to neurogenic shock, and more aggressive fluid resuscitation or pharmacological support is needed.
Choice C reason: Raising the head of the bed is not appropriate for managing the patient's condition. In fact, keeping the head elevated can worsen hypotension by reducing venous return to the heart. The focus should be on stabilizing blood pressure and heart rate.
Choice D reason: The correct intervention is starting a dopamine IV drip. Dopamine is a vasopressor that helps increase blood pressure and heart rate, which is crucial in managing neurogenic shock. By administering dopamine, the nurse can help stabilize the patient's cardiovascular status and improve perfusion to vital organs.
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