An emergency department nurse has just admitted a client with a burn. The burn area is the anterior upper chest and left anterior arm. Using the rule of nine, what would be the extent of the burn injury?
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A nurse is caring for a client who was hit on the left side…
A nurse is caring for a client who was hit on the left side of the head with a baseball bat. Which of the following assessments should the nurse perform?
An ED nurse is triaging clients according to the Emergency S…
An ED nurse is triaging clients according to the Emergency Severity Index (ESI). When assigning clients to a triage level, the nurse will consider the clients’ acuity as well as what other variable?
A client is receiving a unit of PRBC due to GI bleeding. The…
A client is receiving a unit of PRBC due to GI bleeding. The nurse assesses the client after 15 minutes and the client complains of flank pain develops urticaria and shortness of breath. The nurse suspects [condition]. The nurses priority action is [priority] and to monitor [parameter]
The nurse is caring for a client with a traumatic brain inju…
The nurse is caring for a client with a traumatic brain injury receiving dexamethasone (Decadron) 4 mg IV every 6 hours. The client’s vital signs are Temperature: 99.0°F BP: 160/90 HR: 120 Respirations: 16 O2 Sat: 95%. Yesterday the client weighed: 67.2 kg. Which of the following assessment information would require immediate intervention?
The nurse is caring for a client in the ICU whose condition…
The nurse is caring for a client in the ICU whose condition is deteriorating. The nurse receives orders to initiate an infusion of dobutamine. What would be the priority assessment and interventions specific to the administration of vasoactive medications? Select all that apply.
A client presents to the emergency department with complaint…
A client presents to the emergency department with complaints of generalized weakness. The nurse suspects systemic inflammatory response syndrome. What are expected additional findings upon assessment? Select All That Apply.
When caring for a patient in shock, one of the major nursing…
When caring for a patient in shock, one of the major nursing goals is to reduce the risk that the patient will develop complications of shock, how can the nurse best achieve this goal?
A high school football player is brought to the emergency de…
A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather, the rectal temperature is 104.9 degrees Fahrenheit. The nurse implements which priority intervention to control the client’s temperature?
The nurse is caring for a client diagnosed with septic shoc…
The nurse is caring for a client diagnosed with septic shock. The most recent vital signs are T-101.0, P- 110, RR-22, BP 101/68. The nurse explains to the new graduate that based on the current vital signs, the client is experiencing which stage of shock?