A client is rescued from an enclosed-space fire with facial burns and suspected smoke inhalation. For each finding or intervention, select the best classification.
Matrix
Choose your responses, then check the answer.
Explanation
Progressive hoarseness or stridor and carbonaceous sputum with respiratory distress suggest inhalation injury and impending airway compromise. Give humidified 100% oxygen, assess for carbon monoxide exposure, and prepare early definitive airway management before edema progresses. For a major burn, establish IV access and titrate prescribed crystalloid using physiologic response such as urine output; do not wait for a chest radiograph to become abnormal before protecting a threatened airway.
Quick answer Treat progressive voice change, stridor, soot with respiratory distress, and facial edema as an airway emergency. Give humidified 100% oxygen, mobilize early intubation support, and begin monitored burn resuscitation.
Why this is correct Thermal injury and smoke exposure can produce rapidly progressive upper-airway edema. Carbon monoxide also impairs oxygen delivery even when conventional pulse oximetry appears reassuring. Airway protection is safer before swelling makes intubation difficult.
Easy analogy or mental picture The airway is a tunnel that is swelling inward. Secure the passage before the opening becomes too narrow.
Memory hook Enclosed fire plus worsening voice or stridor: oxygen now, airway early.
NCLEX decision rule Prioritize airway and oxygenation over wound care. Use the complete cue pattern: isolated singed hair alone does not prove obstruction, but progressive hoarseness, stridor, oral edema, hypoxemia, or impaired mental status requires urgent escalation. Titrate burn fluids to response rather than giving an unmonitored fixed volume.
Why the other choices are wrong A normal early chest radiograph does not exclude inhalation injury. Delaying airway management for imaging can allow edema to progress, and fluid administration without urine-output and hemodynamic reassessment risks both under- and over-resuscitation.
Source
1American Burn Association Clinical Practice Guidelines
2ABA Airway, Ventilator, and Fluid Resuscitation Guidance
32026 NCLEX-RN Test Plan
The client has progressive hoarseness, soot in the mouth, carbonaceous sputum, tachypnea, and increasing facial edema. Humidified 100% oxygen, airway equipment, burn-center consultation, IV access, and prescribed fluid resuscitation are available.
Inhalation injury — Airway and lung injury caused by heat, smoke, or toxic combustion products, often with delayed respiratory deterioration.
Carbonaceous sputum — Dark soot-containing respiratory secretions that support concern for smoke inhalation when interpreted with the full respiratory assessment.
Carboxyhemoglobin — Hemoglobin bound to carbon monoxide, reducing oxygen transport and requiring co-oximetry rather than routine pulse oximetry for measurement.