To evaluate the effectiveness of the pantoprazole (Protonix) ordered for a patient with systemic inflammatory response syndrome (SIRS), which assessment will the nurse perform?

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.

Rationale:

A: Delays airway and breathing by starting with clothing removal and vital signs.

B: Places Foley insertion and clothing removal before IV access and exposure priorities.

C: Begins with vital signs and delays oxygen and airway management, which is unsafe in trauma.
D. This question follows trauma priority care using the ABCDE approach (Airway, Breathing, Circulation, Disability, Exposure).

1. Assess for spontaneous respirations (1)
   This is the first priority. The nurse must immediately determine whether the client is breathing. Without respirations, all other interventions are secondary.
2. Open the airway using chin lift or jaw thrust (7)
   If respirations are compromised or at risk, the airway must be opened next. In trauma, the jaw thrust is preferred to protect the cervical spine.
3. Give supplemental oxygen per mask (2)
   Once the airway is open and breathing is assessed, oxygen is administered to prevent hypoxia, which can rapidly worsen outcomes in trauma patients.
4. Secure/start two large-bore IVs with normal saline (6)
   After airway and breathing are addressed, attention turns to circulation. Large-bore IV access allows for rapid fluid resuscitation to treat or prevent shock.
5. Remove the patient’s clothing (5)
   This step supports exposure, allowing the nurse to fully assess for hidden injuries, bleeding, or deformities. It occurs after life-threatening ABC issues are managed.
6. Obtain a full set of vital signs (4)
   Vital signs are important but should be obtained after immediate threats to airway, breathing, and circulation are controlled.
7. Insert a Foley catheter if not contraindicated (3)
   This is a lower-priority intervention used to monitor urine output and renal perfusion. It should be delayed until the client is stabilized and contraindications (e.g., pelvic trauma) are ruled out.