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Nurses’ Notes   2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral superficial partial thickness and deep partial thickness burns to the front of both legs, the entire right arm and the chest from a house fire that occurred at 1800 today. Client weighs 242 lbs.   Fluid resuscitation started with Lactated Ringer’s IV in the emergency department. 2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Breath sounds clear.  Client begins to appear edematous. Doppler pedal pulses present. A triple-lumen subclavian central venous line has been inserted to monitor the client’s central venous pressure (CVP). 2105: Physician notified of vital signs and output. 500 mL bolus of LR ordered and infused. Vital Signs Time 2000 2100 2200 Temperature 37.8 C/100 F 37.5 C/99.5 F 35.6 C/96 F Heart rate 130 135 120 Respirations 28 32 36 Blood Pressure 88/58 80/54 98/60 Pulse oximeter 92 on 4L NC 98 on 100% NRB 89 on 100% NRB Pain 6/10 4/10 7/10 CVP   3 mmHg 5 mmHg Intake & Output Hour 2000 2100 2200 IV rate As ordered As ordered As ordered IV intake Started 689 mL 1813 mL Output   20 mL 125 mL   Based on the 2200 assessment findings above, what is the priority nursing action?  

A patient is being treated in the emergency department for shock of unknown origin. The first action by the nurse should be to

Refrigerant leaves the compressor discharge line and enters the condenser as a _____.

A laboratory technician accidentally spilled a corrosive chemical on her forearm. She immediately rinsed the affected area for a few minutes before coming to the emergency department. Upon assessment, you note redness, blistering, and superficial tissue destruction. What is the most appropriate initial nursing intervention?

The nurse is admitting a patient with advanced heart failure in the emergency department. Which type of shock is the patient at the greatest risk for?

The drop in pressure as refrigerant passes through the metering device _____ the boiling point of the refrigerant.

A 60 year old patient is admitted to the emergency department with signs and symptoms of cardiogenic shock, including hypotension, tachycardia, and pulmonary edema. The nurse anticipates which of the following treatments as a priority for this patient? 

A client sustained burn injuries at 4pm this evening when an excavator he was operating caught fire. The client weighs 248 pounds. There are deep partial thickness and full thickness burns to the front of both legs, his perineum and abdomen. The client arrives at the emergency department at 7pm. Calculate the client’s initial rate of IV infusion. Round to the nearest whole number if needed. 

A nurse is caring for a patient who sustained a 45% TBSA burn 24 hours age. The client is exhibiting signs and symptoms of a pulmonary embolism. Which of the following factors contribute to the elevated risk of venous thromboembolsim (VTE) in burn patients? Select all that apply

A 35-year-old patient is brought into the emergency department after being involved in a house fire. Upon assessment, the nurse observes areas of charred, leathery skin with insensitivity to touch over the affected areas. The nurse recognizes these findings as indicative of which type of burn?