The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Administer morphine 5 mg intravenously.

Administer a tetanus immunization.

Assist the client to cough and deep breathe.

Listen to breath sounds.

Answer and Explanation

The Correct Answer is D

Choice A reason: Morphine for pain is important but secondary to assessing airway and breathing in burns, as chest involvement risks respiratory compromise. Listening to breath sounds ensures stability, making this incorrect, as it’s less urgent than the nurse’s priority of respiratory assessment.

Choice B reason: Tetanus immunization prevents infection but is not urgent in acute burn management. Breath sounds assess respiratory status, critical with chest burns, making this incorrect, as it’s secondary to the nurse’s first action of ensuring airway and breathing stability.

Choice C reason: Coughing and deep breathing support respiratory function but assume stable breathing. Listening to breath sounds confirms airway patency in chest burns, making this incorrect, as it’s less immediate than the nurse’s priority of assessing respiratory status first.

Choice D reason: Listening to breath sounds is the first action to assess for respiratory compromise in deep partial thickness chest burns, as restlessness may indicate hypoxia. This aligns with burn care priorities, making it the correct action for the nurse to take initially.

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Correct Answer is B

Explanation

Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.

Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.

Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.

Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.

A. pH: 7.40, PaO2: 90 mm Hg, CO2: 39 mEq/L, HCO3: 23 mEq/L. B. pH: 7.32, PaO2: 85 mm Hg, CO2: 57 mEq/L, HCO3: 26 mEq/L. C. pH: 7.47, PaO2: 82 mm Hg, CO2: 30 mEq/L, HCO3: 31 mEq/L. D. pH: 7.30, PaO2: 95 mm Hg, CO2: 22 mEq/L, HCO3: 19 mEq/L.

Correct Answer is B

Explanation

Choice A reason: Normal ABG values (pH 7.40, CO2 39) don’t reflect COPD’s chronic hypercapnia and compensated acidosis. pH 7.32 with elevated CO2 is typical, making this incorrect, as it doesn’t match the nurse’s expected findings in a client with chronic obstructive pulmonary disease.

Choice B reason: In COPD, chronic CO2 retention (57 mEq/L) causes respiratory acidosis (pH 7.32) with compensatory HCO3 increase (26 mEq/L). Low PaO2 (85 mm Hg) reflects hypoxemia. This aligns with COPD pathophysiology, making it the correct ABG finding the nurse anticipates in this client.

Choice C reason: Alkalotic pH (7.47) and low CO2 (30 mEq/L) suggest hyperventilation, not COPD’s CO2 retention. Acidosis with high CO2 is expected, making this incorrect, as it contradicts the typical ABG profile in the nurse’s assessment of a COPD client.

Choice D reason: Low CO2 (22 mEq/L) and acidosis (pH 7.30) suggest metabolic acidosis, not COPD’s respiratory acidosis with hypercapnia. Elevated CO2 is typical, making this incorrect, as it doesn’t reflect the nurse’s expected ABG findings in chronic obstructive pulmonary disease.

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The nurse cares for a client in the emergency department diagnosed with deep partial thickness burns of the arms and chest. The nurse notes that the client is very restless and anxious. Which action should the nurse take FIRST?

Nursing Test Bank

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