Author Question: A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later ... (Read 118 times)

Chelseaamend · **on:** Jun 25, 2018

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take?

a. Document the findings and reassess in 1 hour.
b. Loosen any constrictive dressings on the chest.
c. Raise the head of the bed to a semi-Fowler's position.
d. Gather appropriate equipment and prepare for an emergency airway.

Question 2

A nurse uses the rule of nines to assess a client with burn injuries to the entire back region and left arm. How should the nurse document the percentage of the client's body that sustained burns?

a. 9
b. 18
c. 27
d. 36

sailorcrescent · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: D
Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

Answer to Question 2

ANS: C
According to the rule of nines, the posterior trunk, anterior trunk, and legs each make up 18 of the total body surface. The head, neck, and arms each make up 9 of total body surface, and the perineum makes up 1. In this case, the client received burns to the back (18) and one arm (9), totaling 27 of the body.