You are a nursing student on a community health clinical rotation. An 85-year-old woman is involved in a house fire. As she attempted to escape, she fell hit her head, and was briefly engulfed in flames and smoke before being rescued.
She is now conscious but confused, lying on a stretcher outside the home. Her clothes are singed, and she has visible burns on her arms and chest, with labored breathing Which of the following signs would indicate a possible inhalation injury?
Soot around nose and mouth, hoarse voice, singed nasal hair
Low blood pressure and cold, clammy skin
Clear lung sounds and strong peripheral pulses
Low blood pressure and cold, clammy skin
The Correct Answer is A
Rationale:
A. Soot around the nose and mouth, hoarse voice, and singed nasal hair is correct because these are classic early indicators of inhalation injury. Inhalation injuries occur from thermal, chemical, or smoke exposure, damaging the upper and sometimes lower airway. Other signs include facial burns, stridor, coughing, labored breathing, and carbonaceous sputum. Early recognition is critical because airway edema can progress rapidly, requiring immediate assessment, supplemental oxygen, and possible intubation to prevent respiratory failure.
B. Low blood pressure and cold, clammy skin is incorrect because these signs indicate hypovolemic or distributive shock, not inhalation injury. While hypotension may occur in burn patients due to fluid loss from extensive burns, it does not specifically identify airway involvement. Hypotension and poor perfusion are systemic signs rather than indicators of inhalation injury.
C. Clear lung sounds and strong peripheral pulses is incorrect because these findings indicate adequate ventilation, oxygenation, and circulation. In a patient with potential inhalation injury, clear lung sounds and strong pulses do not suggest airway compromise, so these findings would not be expected in early or progressing inhalation injury. Relying on normal lung sounds can delay recognition of upper airway edema, which may develop before lower airway signs appear.
D. Low blood pressure and cold, clammy skin is repeated and incorrect for the same reason as B. These findings reflect shock and poor perfusion but do not provide any direct evidence of inhalation injury. Focusing on these signs alone could delay airway intervention, which is the priority in suspected smoke or thermal inhalation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Rapid breathing (tachypnea) alone does not significantly prevent oxygenation. While it may cause fatigue over time, it is not the primary reason oxygen saturation remains low in pulmonary embolism.
B. Acute respiratory distress syndrome (ARDS) is a different condition. While ARDS also impairs oxygenation, the patient has a pulmonary embolism, so the cause of hypoxemia is different.
C. Immediate intubation is not automatically indicated for every patient with pulmonary embolism. Many patients can maintain adequate oxygenation with supplemental oxygen unless they develop severe respiratory failure.
D. A pulmonary embolism obstructs blood flow in the pulmonary arteries, causing a ventilation-perfusion (V/Q) mismatch. Oxygen can reach the alveoli, but blood flow is blocked, so oxygen cannot be effectively transferred into the circulation, resulting in persistent hypoxemia despite supplemental oxygen.
Correct Answer is C
Explanation
Rationale:
A. This is partially correct because emotional support is important for patient and family well-being, but according to the Synergy Model, optimal outcomes are achieved when the nurse’s clinical competencies are matched to the patient’s level of acuity and complexity, not solely emotional needs.
B. While specialized clinical knowledge and problem-solving skills are important, this option is less comprehensive than option C because it does not emphasize the nurse’s ability to anticipate needs, make rapid decisions, and manage complex critical care situations.
C. Correct. The Synergy Model of nursing emphasizes that patient outcomes are optimized when the nurse’s competencies align with the patient’s needs. For a critically ill patient with multiple comorbidities, this means matching high-acuity needs with a nurse who has advanced critical care expertise, can anticipate complications, and make rapid, accurate decisions. The synergy between patient needs and nurse competencies ensures safe, effective, and holistic care.
D. Strong time management and organizational skills are beneficial but do not fully address the complexity and acuity of a critically ill patient. These skills support efficiency but are not sufficient alone to optimize outcomes according to the Synergy Model.
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