The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?
Notify the physician and anticipate the need for endotracheal intubation
Place the client in semi-fowler's position and administer albuterol breathing treatment
Encourage the client to cough, take deep breaths, and then auscultate again
Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
The Correct Answer is A
A. Notify the physician and anticipate the need for endotracheal intubation
The client is showing progressive airway obstruction due to inhalation injury. The absence of wheezes indicates impending respiratory failure, requiring immediate airway management.
B. Place the client in semi-Fowler's position and administer an albuterol breathing treatment
Albuterol may help bronchospasm, but this client's issue is upper airway swelling, not bronchospasm. Intubation is the priority.
C. Encourage the client to cough, take deep breaths, and then auscultate again
The loss of wheezes suggests airway swelling has worsened, not that secretions are the issue. Immediate intervention is needed.
D. Recommend a medical prescription for guaifenesin and encourage use of incentive spirometry
Guaifenesin and incentive spirometry help with secretion clearance, but they are not the priority in this emergent airway situation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Prepare for immediate abdominal surgery
There is no indication of active hemorrhage or peritonitis at this point. Further assessment is needed before deciding on surgery.
B. Determine if there are any allergies to food or drugs
Allergy history is important, but it is not the immediate priority for this client.
C. Administer antibiotics as ordered after culture results are available
Antibiotics may be needed if infection is suspected, but the priority is assessing kidney function due to the risk of rhabdomyolysis from muscle breakdown.
D. Obtain a urine specimen
Flank pain after a crush injury suggests possible rhabdomyolysis or kidney damage. The urine should be tested for myoglobinuria (tea-colored urine), hematuria, or kidney injury markers.
Correct Answer is ["70"]
Explanation
- Formula: Dose = Weight (kg) × 80 units/kg
- 5600 units ÷ 80 units/kg = 70 kg
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