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A client with a severe allergy develops wheezing, stridor, and respiratory distress after exposure to an allergen. What is the nurse's priority action?
Elevate the head of the bed immediately and remove the trigger if known
A client presents with sudden onset dyspnea and chest pain. The nurse suspects a pneumothorax. Which assessment finding supports this diagnosis?
Diminished or absent breath sounds on the affected side
Which assessment is most important when evaluating the effectiveness of mechanical ventilation?
Arterial blood gas levels
The greatest cause of mortality during the emergent phase of burn injury is:
Hypovolemia
Which nursing action is essential before a client undergoes MRI testing?
Remove all metal-containing objects
A client is admitted with mild carbon monoxide poisoning. What is the priority nursing intervention?
Administer oxygen by nasal cannula
A client with status epilepticus continues to seize despite administration of lorazepam. What is the nurse's next priority action?
Immediately sedate and intubate the client as ordered
The water-seal chamber of a chest tube drainage system is continuously bubbling. How should the nurse interpret this finding?
The system has an air leak
A client with extensive burns develops hypotension and tachycardia. What is the priority nursing intervention?
Administer IV fluids
A client scheduled for EEG testing should receive which instruction?
Avoid caffeine the morning before the procedure
A client is suspected of inhalation injury after a house fire. Which nursing action is the highest priority?
Apply oxygen and continuous pulse oximetry
A client develops sudden respiratory distress after central line placement. What complication should the nurse suspect first?
Pneumothorax
A burn injury that destroys the epidermis, dermis, and underlying tissue is classified as which type of burn?
Full-thickness
Which intervention helps prevent contractures during burn rehabilitation?
Encourage physical activity and range-of-motion exercises
Which medication is commonly administered to reduce cerebral edema following traumatic brain injury?
Mannitol
A client with expressive aphasia following a stroke is frustrated because they cannot communicate their needs. What nursing intervention is most appropriate?
Use a picture board and allow the client to point to pictures
Which intervention is most effective in preventing postoperative respiratory complications?
Early ambulation
Burn injuries are categorized into which phases of treatment?
Emergent, acute, and rehabilitative
When applying topical antimicrobial cream to a burn wound, the nurse should:
Apply a layer approximately 1/16 inch thick
A client with traumatic brain injury has a Glasgow Coma Scale score of 6. What is the nurse's highest priority?
Maintain a patent airway
Which interventions should the nurse include when caring for a client with increased intracranial pressure (ICP)? Select all that apply.
Elevate the head of the bed 30 degrees
Maintain neutral head alignment
Limit suctioning to only when necessary
Which airway device provides the most definitive airway protection for a critically ill client?
Endotracheal tube
Which laboratory findings are commonly seen in the emergent phase of severe burns?
Hyperkalemia, hyponatremia, elevated hematocrit
A client has personality changes, impaired judgment, and inappropriate behavior following a traumatic brain injury. Which lobe is most likely affected?
Frontal lobe
A client with increased intracranial pressure is being monitored in the ICU. Which nursing intervention helps maintain cerebral perfusion pressure (CPP)?
Participate in interventions to increase CPP and reduce ICP