Author: Anonymous

The nurse is reinforcing teaching with a client in the rehabilitation phase following a major burn injury. Which client statement indicates a correct understanding of the nurse’s teaching?  

Failure to rescue occurs when death is due to failure or delay in [intervention]  and responding to a hospitalized client experiencing complications.

A 19-year-old client arrives in the ED with abdominal pain, vomiting, and deep, rapid breathing. Blood glucose is 540 mg/dL, and arterial blood gas shows:  pH 7.25           PaCO₂ 28 mmHg           HCO₃⁻ 14 mEq/L Normal Range pH: 7.35 – 7.45 PaCO2: 35- 45 PaO2: 80-100 HCO3: 22-26  Which of the following nursing actions should the nurse perform first?  

Which physician order should the nurse question for a client showing early signs of fulminant hepatitis (jaundice, fatigue, RUQ pain, coagulopathy)? 

A patient involved in a high‑speed motor vehicle collision (MVC) initially stabilizes after resuscitation. Which finding during ongoing care would be most concerning for missed injury? 

A nurse is assessing a client in the emergency department with a suspected upper GI bleed. The client is alert and anxious, with a heart rate of 120/min, blood pressure of 118/76 mmHg, cool clammy skin, and delayed capillary refill.  Which interpretation best explains why the blood pressure is still within normal limits? 

A nurse is caring for a client with acute leukemia who received the first dose of chemotherapy 18 hours ago. Which assessment finding is most concerning for early tumor lysis syndrome? 

A client experienced a full-thickness burn 72 hours ago. The client’s vital signs are as follows: BP: 124/72 mmHg HR: 97/min Urine output: 50 mL/hr The nurse understands that the client is in the [phase] of burn management and anticipates [intervention] 

A client with decompensated cirrhosis is admitted with jaundice, confusion, and increasing abdominal distention. Which assessment finding requires immediate intervention?   

A nurse is caring for a client who has just arrived to the emergency department following a high-speed motor vehicle collision. The client is immobilized on a backboard with a cervical collar in place. The client is groaning, has blood and vomitus in the mouth, and cannot speak in full sentences.  Which action should the nurse take first?