A patient is admitted to the burn unit with burns of the head, neck, chest, and back following a garage fire. Upon admission to the unit, the nurse auscultates wheezes in the patient's lungs. One hour later, the wheezes cannot be heard, and lung sounds are decreased. The most appropriate action by the nurse is to

place the patient in high-Fowler's position.

encourage the patient to cough and auscultate the lungs again.

document the results and continue to monitor the ventilation.

notify the health care provider about the breath sounds.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Placing the patient in high-Fowler’s position is incorrect because while it can improve ventilation, the disappearance of wheezes with decreased or absent breath sounds may indicate progressive airway obstruction, which is life-threatening and requires immediate provider notification. Positioning alone will not prevent airway compromise.

B. Encouraging the patient to cough and auscultating again is incorrect because the patient may have airway edema from inhalation injury, and attempting to cough may not relieve obstruction or alert staff to impending respiratory failure. This delays urgent intervention.

C. Documenting the results and continuing to monitor is incorrect because absent or decreased breath sounds in a patient with inhalation injury is an emergency. Waiting could result in complete airway obstruction and respiratory arrest.

D. Notifying the health care provider is correct because the loss of previously audible wheezes and decreased lung sounds indicates worsening airway edema or obstruction, which requires immediate evaluation and possible airway intervention (e.g., intubation). Rapid assessment and provider notification are critical to prevent respiratory failure.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Inserting an oropharyngeal airway is used to maintain patency in patients who still have some spontaneous breathing but are at risk of airway obstruction, such as those who are unconscious. It is not sufficient for a patient who cannot maintain respirations.
B. The jaw thrust maneuver is an emergency technique used to open the airway in trauma patients with suspected cervical spine injury. It is temporary and supportive, not definitive management for respiratory failure.
C. Endotracheal intubation is the definitive airway intervention for patients who cannot maintain spontaneous respirations. It secures the airway, allows mechanical ventilation, and ensures adequate oxygenation and ventilation. This is the most appropriate intervention in respiratory insufficiency.
D. Cricothyroidotomy is an emergency surgical airway performed when endotracheal intubation is impossible, such as in severe facial trauma or upper airway obstruction. It is not the first-line approach if standard intubation is feasible.

A. WBC 13.8 B. Hgb 14.4 C. Platelets 98 D. Glucose 140 E. Lactate 3.2

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

Explanation

Rationale:
A. WBC 13.8 is correct because leukocytosis indicates infection or systemic inflammatory response, consistent with her urinary symptoms and altered mental status. This lab result supports the need for immediate evaluation and treatment of a suspected urinary tract infection or sepsis.

B. Hgb 14.4 is incorrect because this value is within normal limits for an adult female and does not indicate acute pathology requiring intervention.

C. Platelets 98 is correct because thrombocytopenia (<150,000) may indicate consumption from sepsis or early disseminated intravascular coagulation (DIC). Low platelets increase the risk for bleeding and are clinically significant in a patient with suspected infection.

D. Glucose 140 is incorrect because this value is mildly elevated and may be stress-induced hyperglycemia, which is common in acute illness. While it should be monitored, it does not require immediate intervention.

E. Lactate 3.2 is correct because elevated serum lactate (>2 mmol/L) indicates tissue hypoperfusion and risk of severe sepsis or septic shock. This is a critical finding requiring urgent recognition and intervention, such as fluid resuscitation, antibiotics, and close hemodynamic monitoring.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is experiencing respiratory insufficiency and cannot maintain spontaneous respirations. The nurse suspects that the physician will perform which of the following actions?

Correct Answer is C

Explanation

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

Explanation

A nurse assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?

A 43 year old male presents to the ER following an MVC with paralysis of the arms and legs and loss of sensation below the shoulders. VS: BP 70/40; HR 48; RR 16; SpO2 81%. When anticipating treatment for this patient's condition, the nurse recognizes the priority goal of treatment is to:

Which of the following clinical manifestations are suggestive of the systemic inflammatory response syndrome (SIRS)? Select all that apply.

The nurse is caring for a patient in the ICU who has been diagnosed with multiple organ dysfunction syndrome (MODS). The nurse's plan of care should include which of the following interventions?

Which client would be most at risk for developing disseminated intravascular coagulation (DIC)?

The client is admitted to the hospital with two of the systemic inflammatory response system (SIRS) variables: T: 95° F and high white blood cell count. What is the priority of care for the patient?