Your patient with facial burns from a house fire is being assessed in the Emergency Department. He begins to develop hoarseness, stridor, and difficulty speaking. What is the priority nursing action?
Monitor vital signs every 15 minutes
Place the patient in high Fowler's position
Notify the physician and prepare for intubation
Administer high-flow oxygen via non-rebreather mask
The Correct Answer is C
Rationale:
A. Monitoring vital signs every 15 minutes is incorrect because while ongoing monitoring is important, this patient is showing signs of impending airway obstruction, which requires immediate intervention. Simply monitoring is not sufficient.
B. Placing the patient in high Fowler’s position is incorrect because positioning may help with comfort and breathing, but it does not address the critical airway threat posed by inhalation injury or upper airway edema.
C. Notifying the physician and preparing for intubation is correct because hoarseness, stridor, and difficulty speaking are early indicators of airway compromise due to inhalation injury or facial burns. Airway edema can progress rapidly, making early, controlled intubation the priority before the airway becomes completely obstructed.
D. Administering high-flow oxygen via non-rebreather mask is incorrect as the sole intervention because oxygen alone will not prevent airway obstruction. While supplemental oxygen may be supportive, the priority is securing the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["11520"]
Explanation
Rationale:
Step 1: % of body burned:
- Front of chest and abdomen: 18%
- Left arm: 9%
- Front of right leg: 4.5%
- Face and neck: 4.5%
Total burned = 36%
Step 2: Parkland formula:
4 × weight (kg) × % burned = 4 × 80 × 36 = 11,520 ml in 24 hours
Step 3: Give fluids:
- First 8 hours: half → 5,760 ml
- Next 16 hours: half → 5,760 ml
Total 24-hour fluid requirement = 11,520 ml
Answer: 11,520 ml
Correct Answer is ["B","C","D","E"]
Explanation
Rationale:
A. Hypokalemia is incorrect because dialysis is not initiated for low potassium levels. In fact, dialysis can further lower potassium and worsen hypokalemia. Dialysis is indicated for dangerously high potassium levels that are unresponsive to medical management.
B. Volume overload is correct because impaired kidney function leads to fluid retention, which can cause pulmonary edema, hypertension, and heart failure. Dialysis removes excess fluid when diuretics are ineffective or contraindicated.
C. Uremia is correct because accumulation of nitrogenous waste products (such as urea and creatinine) can cause symptoms like altered mental status, pericarditis, nausea, vomiting, and bleeding. Dialysis removes these toxins from the blood.
D. Hyperkalemia is correct because elevated potassium levels can cause life-threatening cardiac dysrhythmias. Dialysis rapidly lowers serum potassium when medical treatment is insufficient or when potassium levels are critically high.
E. Acidosis is correct because severe metabolic acidosis occurs when the kidneys cannot excrete hydrogen ions or regenerate bicarbonate. Dialysis helps correct acid–base imbalance when acidosis is refractory to other treatments.
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