The nurse is caring for a 17-year-old male involved in a hou…

The nurse is caring for a 17-year-old male involved in a house fire who sustained 2nd and 3rd degree burns to the anterior and posterior aspects of both legs, the entire anterior chest and abdomen, and entire posterior back. Given the burn surface area sustained, determine the percentage of body surface area burned using the Rule of Nines.  [BLANK-1]%

The nurse is caring for a client admitted following a blunt…

The nurse is caring for a client admitted following a blunt force injury to the left thorax and chest. The client presents with dyspnea, increased work of breathing, hypoxia, and paradoxical chest movement. Upon auscultating the lungs, breath sounds are present bilaterally.  Given the client presentation, which intervention is not a priority?

Due to a motor vehicle accident, the client sustained a trau…

Due to a motor vehicle accident, the client sustained a traumatic brain injury (TBI) and is intubated and sedated. An intraventricular catheter and external ventricular drain (EVD) were placed in the ICU, as well as a foley catheter. Which findings would warrant immediate action by the nurse?

The nurse is caring for a 30-year-old client who underwent a…

The nurse is caring for a 30-year-old client who underwent an exploratory laparotomy after sustaining a gunshot wound to the abdomen. Nursing documentation: The client is 7 hours post-op in the intensive care unit. Rates pain a 4 on the 1-to-10 pain scale. Client appears lethargic, but oriented x4 and cooperative. Lungs clear bilaterally. Abdomen is hard and distended. The nurse notes increasing drainage in the client’s abdominal drain.Vital signs are: Temp 98.1, HR 122, BP 89/50, RR 26, O2 94% on RA.