Difficulty: Medium
Average Score: 77%
Simulated
The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?
Correct answer
A
Rationale
The absence of wheezes, decreased lung sounds, hoarseness, and gray sputum indicate progressive airway obstruction from inhalation injury, requiring immediate intubation.