A nurse assesses a client who has burn injuries and notes ...

[Haya94]

A nurse assesses a client who has burn injuries and notes crackles in bilateral lung bases, a respiratory rate of 40 breaths/min, and a productive cough with blood-tinged sputum. Which action should the nurse take next?
 
  a. Administer furosemide (Lasix).
  b. Perform chest physiotherapy.
  c. Document and reassess in an hour.
  d. Place the client in an upright position.

Question 2

A nurse cares for a client with a burn injury who presents with drooling and difficulty swallowing. Which action should the nurse take first?
 
  a. Assess the level of consciousness and pupillary reactions.
  b. Ascertain the time food or liquid was last consumed.
  c. Auscultate breath sounds over the trachea and bronchi.
  d. Measure abdominal girth and auscultate bowel sounds.

[taylorsonier]

Answer to Question 1

ANS: D
Pulmonary edema can result from fluid resuscitation given for burn treatment. This can occur even in a young healthy person. Placing the client in an upright position can relieve lung congestion immediately before other measures can be carried out. Although Lasix may be used to treat pulmonary edema in clients who are fluid overloaded, a client with a burn injury will lose a significant amount of fluid through the broken skin; therefore, Lasix would not be appropriate. Chest physiotherapy will not get rid of fluid.

Answer to Question 2

ANS: C
Inhalation injuries are present in 7 of clients admitted to burn centers. Drooling and difficulty swallowing can mean that the client is about to lose his or her airway because of this injury. Absence of breath sounds over the trachea and bronchi indicates impending airway obstruction and demands immediate intubation. Knowing the level of consciousness is important in assessing oxygenation to the brain. Ascertaining the time of last food intake is important in case intubation is necessary (the nurse will be more alert for signs of aspiration). However, assessing for air exchange is the most important intervention at this time. Measuring abdominal girth is not relevant in this situation.

[Haya94]

Excellent

[xthemafja]

TYSM