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

Answer and Explanation

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

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A. Administer each unit of blood over 3–4 hours

Older clients with CHF cannot tolerate rapid fluid shifts. Blood should be administered slowly (over 3–4 hours per unit) to prevent fluid overload.

B. Anticipate an order for acetaminophen

Acetaminophen is not routinely given before blood transfusions unless the client has a history of febrile reactions.

C. Anticipate an order for furosemide administration

Loop diuretics like furosemide may be ordered between units to prevent fluid overload in CHF patients.

D. Assess for signs and symptoms of fluid overload

CHF patients are at high risk for fluid overload, leading to dyspnea, crackles, and increased BP.

E. Anticipate administration of fresh frozen plasma (FFP) for the next transfusion

FFP is given for coagulation disorders, not for treating anemia in a GI bleed.

A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN B. With one other CNA logroll a client who has had a bicycle accident C. Obtain a weight on a newly admitted client with diabetes D. Assist a client to the bathroom 1 hour after a lumbar puncture

Correct Answer is C

Explanation

A. Review dietary approaches to stop hypertension (DASH) choices in a client with primary HTN
Dietary education requires nursing judgment and assessment, which are outside the CNA’s scope of practice. This should be done by the RN or a dietitian.

B. With one other CNA, logroll a client who has had a bicycle accident
Logrolling is required in patients with spinal precautions, and an RN or physical therapist should oversee or perform the procedure to ensure proper spinal alignment.

C. Obtain a weight on a newly admitted client with diabetes
Measuring weight is within a CNA’s scope of practice, and it does not require clinical judgment. The CNA can obtain the weight and report findings to the RN.

D. Assist a client to the bathroom 1 hour after a lumbar puncture
A client who has undergone a lumbar puncture is at risk for post-procedure headaches and hypotension due to cerebrospinal fluid loss. The RN should assess the client first before allowing ambulation.

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

The nurse is caring for an 82-year-old client with a history of coronary artery disease. ML. and CHF. The client is to receive 2 units of packed red blood cells for acute blood loss from a Grbleed. What would be the nursing priorities for blood administration of this client? (Select All that Apply)

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

Explanation

Which action is safest for the registered nurse (RN) to delegate to the certified nursing assistant (CNA)?

Correct Answer is C

Explanation

How should the nurse evaluate the client's motor ability and function?

What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

The nurse is caring for a client who has completed a blood product transfusion for the treatment of thrombocytopenia. How would the nurse know that treatment has been successful?

A client receiving treatment for severe burns over more than half of his body has an indwelling urinary catheter inserted. When evaluating the client's intake and output, which of the following should be taken into consideration? The amount of urine:

The nurse is caring for a client with trigeminal neuralgia. Which medical prescription would the nurse anticipate?

A client with hypovolemic shock who did not respond to fluid resuscitation is started on norepinephrine. What is the desired outcome?