A nurse is caring for a client with 25% full thickness burns on the arms, face, neck and shoulders. The client's voice is hoarse and has a brassy cough. These finding indicate that the client most likely has
pulmonary edema.
pneumonia.
inhalation injury.
carbon-monoxide poisoning
The Correct Answer is C
A. pulmonary edema: Pulmonary edema presents with crackles, dyspnea, and frothy sputum, but it does not typically cause a hoarse voice or a brassy cough. These findings point more specifically to airway irritation rather than fluid accumulation in the lungs.
B. pneumonia: Pneumonia usually causes fever, productive cough, and abnormal breath sounds. It does not typically produce hoarseness or a brassy cough immediately after a burn injury, making it a less likely explanation for these acute airway symptoms.
C. inhalation injury: Hoarseness and a brassy cough strongly suggest thermal or chemical injury to the upper airway. Burns to the face, neck, and shoulders increase the likelihood of smoke inhalation, and these symptoms indicate airway swelling, which can rapidly progress to obstruction.
D. carbon-monoxide poisoning: Carbon monoxide poisoning presents with headache, confusion, and cherry-red skin coloration, but it does not cause hoarseness or irritation of the airway. A brassy cough is not characteristic of this condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Cool, clammy skin: During the compensatory stage of shock, the sympathetic nervous system triggers peripheral vasoconstriction to maintain blood flow to vital organs. This shunts blood away from the skin, causing it to become cool and moist. These changes reflect early compensatory mechanisms attempting to stabilize perfusion.
B. Decreased heart rate: A decreased heart rate is not expected in the compensatory stage, as the body typically increases heart rate to maintain cardiac output. Sympathetic activation drives tachycardia to compensate for reduced circulating volume. A slowed pulse would suggest a different clinical problem unrelated to early shock.
C. Hyperactive bowel sounds: Shock states generally reduce perfusion to nonessential organs, including the gastrointestinal tract. This leads to diminished or hypoactive bowel sounds, not hyperactivity. Blood flow is redirected to support the heart and brain rather than digestion.
D. Increased urine output: In early shock, the kidneys receive reduced blood flow as the body conserves fluid and maintains central perfusion. This results in decreased, not increased, urine output. Reduced renal perfusion is a key early indicator of volume loss. Increased output contradicts expected physiological responses in shock.
Correct Answer is B
Explanation
A. Phosphate level: Phosphate levels are not directly affected by calcium gluconate administration. Monitoring phosphate is important in kidney disease but does not indicate the immediate effectiveness of calcium gluconate in hyperkalemia.
B. Cardiac rhythm: Calcium gluconate stabilizes cardiac membranes in hyperkalemia but does not lower potassium levels. Monitoring the cardiac rhythm allows the nurse to evaluate whether the medication is preventing life-threatening arrhythmias. This is the primary indicator of effectiveness.
C. Urine output: Urine output reflects kidney function but does not provide immediate information about the cardiac protective effects of calcium gluconate. Changes in urine are unrelated to the acute response to this therapy.
D. Calcium level: While calcium levels may increase slightly, the goal of IV calcium gluconate is membrane stabilization, not correcting hypocalcemia. Monitoring cardiac rhythm is more critical than measuring calcium levels to assess effectiveness.
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