A nurse on a burn unit is caring for a client who experienced burn injuries 36 hours ago. The client is now showing signs and symptoms of airway obstruction, despite appearing stable since admitted. How should the client's change in status be best understood?
The client has likely developed a systemic infection.
The client is likely experiencing an anaphylactic reaction to a medication.
The client's respiratory complications are likely related to psychosocial stress.
The client is likely experiencing a delayed onset of respiratory complications.
The Correct Answer is D
A. The client has likely developed a systemic infection: Systemic infections typically develop later in the course of burn injuries, often after the first 48–72 hours, and present with fever, tachycardia, and other systemic signs. While infection is a concern, it is less likely to explain acute airway obstruction at 36 hours post-burn.
B. The client is likely experiencing an anaphylactic reaction to a medication: Anaphylaxis usually occurs immediately or shortly after exposure to an allergen or new medication. The delayed development of airway obstruction 36 hours after burn injury makes anaphylaxis less likely.
C. The client's respiratory complications are likely related to psychosocial stress: Psychological stress can affect breathing patterns, but it does not cause physical airway obstruction or progressive respiratory compromise. The client’s airway changes are physiological rather than psychosocial in origin.
D. The client is likely experiencing a delayed onset of respiratory complications: Inhalation injuries can cause progressive airway edema that worsens hours after the initial burn. Swelling of the upper airway and bronchial mucosa can lead to obstruction, making this a delayed but serious respiratory complication that requires immediate intervention.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. A client with an open femur fracture: While a femur fracture is serious due to risk of blood loss and fat embolism, it is not immediately life-threatening compared with a compromised airway or chest injury.
B. A client with 1+ pedal pulses: Weak but palpable pedal pulses indicate some distal perfusion. While this requires monitoring, it is not immediately life-threatening compared with a major chest injury.
C. A client with bleeding of scalp lacerations: Scalp lacerations can bleed significantly but are generally controllable with pressure and are not as immediately life-threatening as thoracic injuries.
D. A client with an open chest wound: An open chest wound poses a risk of tension pneumothorax or impaired ventilation, which can quickly become fatal. Airway and oxygenation take priority, making this client the highest treatment priority.
Correct Answer is B
Explanation
A. Increased respiratory rate: An elevated respiratory rate may indicate ongoing respiratory distress or pain rather than improvement. While monitoring respiratory rate is important, an increase does not signify that the chest injury is resolving or that the lung has re-expanded. It may reflect compensatory effort due to hypoxia or discomfort.
B. Increased breath sounds: The return or improvement of breath sounds on auscultation indicates that the previously collapsed or injured lung is re-expanding and ventilation is improving. This is a direct sign that the chest tube is effectively removing air or fluid and that the client is responding positively to treatment.
C. Constant bubbling in the drainage chamber: Continuous bubbling usually suggests an air leak in the chest tube system, which is a complication rather than a desired response. Intermittent bubbling may occur with exhalation, but constant bubbling signals that the system is not fully sealed.
D. Fluctuation of drainage in the tubing: Fluctuation, or tidaling, reflects changes in intrathoracic pressure and is normal initially. While it indicates patency of the tube, it does not directly signify resolution of the lung injury. Over time, the goal is stabilization with minimal fluctuation as the lung fully re-expands
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