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A nurse is admitting a client who sustained severe burns to the entire head, posterior trunk, and posterior surface of the left arm. Using the Rule of Nines, what percentage of total body surface area (TBSA) should the nurse estimate is burned?

A nurse is caring for a client undergoing hemodialysis who suddenly reports feeling lightheaded and nauseated. The nurse notes the client’s blood pressure has dropped from 140/85 mmHg to 98/60 mmHg and observes muscle twitching in the lower extremities. Which action should the nurse take first?

A client with diabetic ketoacidosis (DKA) is receiving continuous IV insulin therapy and has been resuscitated with 0.9% sodium chloride. The nurse notes the client’s most recent blood glucose has decreased to 248 mg/dL. L. Which of the following priority action should the nurse complete?

A group of elementary school children, teachers, and parents were headed on a school field trip and the bus was hit by a semitrailer truck.  The nurses on the scene were asked to triage victims using the triage tags. Which triage category is appropriate for each victim?  Match the victim with the appropriate triage tag. 

The nurse is assessing a client in the acute phase of Guillain-Barré Syndrome (GBS). Which assessment finding requires immediate intervention?

A client with deep frostbite of the lower extremity has completed rapid rewarming. Which nursing intervention is most appropriate to implement next?

A nurse is the triage officer in the emergency department when four clients arrive following a factory explosion. Which client should the nurse assess first?

A client with acute respiratory distress syndrome (ARDS) is intubated and mechanically ventilated. The healthcare provider prescribes a continuous infusion of a neuromuscular blocking agent (NMBA). Which of the following additional medications should the nurse anticipate and notify the provider to order if not already prescribed?

During a trial to wean a client off mechanical ventilation, the nurse notes the following changes: blood pressure increases to 160/90 mmHg, respiratory rate increases to 32 breaths per minute, oxygen saturation drops to 90%, and the client appears restless. What is the nurse’s priority action?

The nurse assesses an adult client who sustained burns to the anterior portions of both legs. According to the Rule of Nines, what percentage of TBSA is burned?