Nokea
An emergency room nurse assesses a client who was rescued from a home fire. The client suddenly develops a loud, brassy cough. Which action should the nurse take first?
- A. Apply oxygen and continuous pulse oximetry.
- B. Provide small quantities of ice chips and sips of water.
- C. Request a prescription for an antitussive medication.
- D. Ask the respiratory therapist to provide humidified air.
Correct Answer: A
Rationale: Brassy cough and wheezing are signs of inhalation injury. The first action by the nurse should be to apply oxygen and monitor with continuous pulse oximetry to ensure adequate oxygenation.
You may also like to solve these questions
The nurse assesses a client who has a severe burn injury. Which statement indicates the client understands the psychosocial impact of a severe burn injury?
- A. It is normal to feel some depression.
- B. I will go back to work immediately.
- C. I will not feel anger about my situation.
- D. Once I get home, things will be normal.
Correct Answer: A
Rationale: During the recovery period, and for some time after discharge from the hospital, clients with severe burn injuries are likely to have psychological problems that require intervention. Depression is one of these problems.
An emergency room nurse cares for a client admitted with a 50% burn injury at 1:00 AM this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number) ml/hr.
- A. 1500 ml/hr
- B. 1000 ml/hr
- C. 2000 ml/hr
- D. 1200 ml/hr
Correct Answer: A
Rationale: The Parkland formula (4 ml/kg/% burn) yields 18,000 ml for a 90-kg client with a 50% burn. Half (9000 ml) should be infused in the first 8 hours. Since infusion starts at noon (11 hours post-burn), 9000 ml must be given over 6 hours, resulting in 1500 ml/hr.
A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take?
- A. Increase the clients oxygen and obtain blood gases.
- B. Draw blood for a carboxyhemoglobin level.
- C. Increase the clients intravenous fluid rate.
- D. Perform a thorough Mini-Mental State Examination.
Correct Answer: B
Rationale: Disorientation and headache are consistent with carbon monoxide poisoning, common in house fire victims. Drawing a carboxyhemoglobin level is the priority to confirm and guide treatment.
A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this clients plan of care to ensure adequate nutrition? (Select all that apply.)
- A. Provide at least 5000 kcal/day.
- B. Start an oral diet on the first day.
- C. Administer a diet high in protein.
- D. Collaborate with a registered dietitian.
- E. Offer frequent high-calorie snacks.
Correct Answer: A,C,D,E
Rationale: Burn patients require a high-calorie (at least 5000 kcal/day), high-protein diet, frequent snacks, and collaboration with a dietitian to meet nutritional needs. Starting an oral diet on the first day may not be feasible due to medical instability.
A nurse cares for a client with severe inhalation injuries who is being monitored in the intensive care unit. Which finding indicates to the nurse that the client is experiencing airway obstruction?
- A. No wheezing or breath sounds
- B. Low oxygen saturation levels
- C. Restlessness and confusion
- D. Elevated respiratory rate
Correct Answer: D
Rationale: Clients with severe inhalation injuries may develop progressive airway obstruction, leading to a loss of wheezing and breath sounds, indicating a critical need for an emergency airway.