An emergency room nurse assesses a patient who was rescued from a home fire.
The patient suddenly develops a loud, brassy cough.
What action would the nurse take first?
Request a prescription for an antitussive medication.
Provide small quantities of ice chips and sips of water.
Ask the respiratory therapist to provide humidified air.
Apply oxygen and continuous pulse oximetry.
The Correct Answer is D
Choice A rationale
A loud, brassy cough in a burn patient rescued from a fire is a critical sign of upper airway edema, often caused by inhalation of hot gases or toxins. This swelling can rapidly lead to complete airway obstruction. Antitussive medications suppress coughing and would mask this vital clinical sign, delaying the necessary and immediate intervention of securing the airway.
Choice B rationale
Providing ice chips or sips of water may be considered for a sore throat, but in the context of a potential inhalation injury, this action is contraindicated. Swelling of the laryngeal and pharyngeal tissues can progress rapidly, and there is a high risk of aspiration if the patient's swallowing reflex is compromised or the airway becomes obstructed.
Choice C rationale
Humidified air can help soothe irritated mucous membranes, but it is not the first action in a patient with a rapidly deteriorating airway. The loud, brassy cough signifies significant laryngeal edema, which can progress to complete obstruction. The immediate priority is to assess, stabilize, and protect the airway with supplemental oxygen and continuous monitoring before it closes.
Choice D rationale
A loud, brassy cough is a hallmark sign of upper airway edema, a serious complication of inhalation injury. The swelling can quickly lead to airway obstruction. Applying oxygen and continuous pulse oximetry is the first action to ensure adequate oxygenation and monitor for signs of impending respiratory failure, while simultaneously preparing for definitive airway management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["1.5"]
Explanation
The patient has an order for Coumadin 3.75 mg today. The pill from the pharmacy is 2.5 mg. How many pills would you give?.
Step 1: Calculate the number of pills needed. 3.75 mg ÷ 2.5 mg = 1.5 pills. The nurse would give 1.5 pills.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale
In the initial stages of hypoxemia, the body's compensatory response involves activating the sympathetic nervous system to increase oxygen delivery. This sympathetic surge leads to vasoconstriction and an increase in heart rate, resulting in elevated blood pressure. This is a temporary mechanism to improve tissue perfusion and is a key early sign before the decompensation phase begins. Normal systolic blood pressure is less than 120 mmHg and diastolic is less than 80 mmHg.
Choice B rationale
Pale skin, or pallor, is an early and observable manifestation of hypoxemia. This is a result of peripheral vasoconstriction, a compensatory mechanism triggered by the sympathetic nervous system to shunt blood from the periphery to vital organs like the heart and brain. This reduction in peripheral blood flow leads to the skin appearing pale, particularly in the extremities and mucous membranes.
Choice C rationale
Confusion is an early and significant neurological sign of cerebral hypoxemia. The brain is highly sensitive to changes in oxygen levels. As oxygen saturation drops, cerebral function is impaired, leading to altered mental status, confusion, restlessness, and anxiety. This is one of the most reliable indicators of impending respiratory failure.
Choice D rationale
Hypotension is typically a late sign of hypoxemia, indicating a state of decompensation and impending circulatory collapse. As the body's compensatory mechanisms fail to maintain adequate cardiac output and oxygen delivery, the patient's blood pressure will drop. This is a critical and ominous finding, suggesting that the patient is in a state of shock and requires immediate intervention
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