Found questions/self assess right answers

The wound, ostomy, and continence (WOC) nurse selects the site where the ostomy will be placed. What should be included in the consideration for the site? The patient must be able to see the site. Outside the rectus muscle area is the best site. It is easier to seal the drainage bag to a protruding area. The ostomy will need irrigation, so area should not be tender.

The patient must be able to see the site

After the diagnosis of disseminated intravascular coagulation (DIC), what is the first priority of collaborative care? Administer heparin. Administer whole blood. Treat the causative problem Administer fresh frozen plasma.

Treat the causative problem

When evaluating the patient's understanding about the care of the ileostomy, what statement by the patient indicates the patient needs more teaching? "I will be able to regulate when I have stools." "I will be able to wear the pouch until it leaks." "Dried fruit and popcorn must be chewed very well." "The drainage from my stoma can damage my skin."

* "I will be able to regulate when I have stools."*

The nurse provides information to a laboratory employee who was accidentally exposed to anthrax by inhalation. The nurse determines the teaching has been successful if the patient makes which statement? "An antibiotic will be prescribed for 2 months." "I will need to wear a mask for the next 2 weeks." "Anthrax can be spread by person-to-person contact." "Antibiotics are only indicated for an active infection."

*"An antibiotic will be prescribed for 2 months."*

After teaching a patient with chronic stable angina about nitroglycerin, the nurse recognizes the need for further teaching when the patient makes which statement? "I will replace my nitroglycerin supply every 6 months." "I can take up to five tablets every 3 minutes for relief of my chest pain." "I will take acetaminophen (Tylenol) to treat the headache caused by nitroglycerin." "I will take the nitroglycerin 10 minutes before planned activity that usually causes chest pain."

*"I can take up to five tablets every 3 minutes for relief of my chest pain."*

In caring for the patient with angina, the patient said, "I walked to the bathroom. While I was having a bowel movement, I started having the worst chest pain ever, like before I was admitted. I called for a nurse, but the pain is gone now." What further assessment data should the nurse obtain from the patient? "What precipitated the pain?" "Has the pain changed this time?" "In what areas did you feel this pain?" "Rate the pain on a scale from 0 to 10, with 0 being no pain and 10 being the worst pain you can imagine."

*"In what areas did you feel this pain?"*

The nurse is caring for a postoperative patient with a colostomy. The nurse is preparing to administer a dose of famotidine (Pepcid) when the patient asks why the medication was ordered since the patient does not have a history of heartburn or gastroesophageal reflux disease (GERD). What response by the nurse would be the most appropriate? "This will prevent air from accumulating in the stomach, causing gas pains." "This will prevent the heartburn that occurs as a side effect of general anesthesia." "The stress of surgery is likely to cause stomach bleeding if you do not receive it." "This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."

*"This will reduce the amount of HCl in the stomach until the nasogastric tube is removed and you can eat a regular diet again."*

A 71-year-old woman arrives in the emergency department after ingesting 8 g of acetaminophen (Tylenol). Which question is most important for the nurse to ask? "Do you feel like you have a fever?" "What time did you take the medication?" "Have you tried to commit suicide before?" "Are you experiencing any abdominal pain?"

*"What time did you take the medication?"*

A patient is admitted with second- and third-degree burns covering the face, entire right upper extremity, and the right anterior trunk area. Using the rule of nines, what should the nurse calculate the extent of these burns as being? 18% 22.5% 27% 36%

*22.5%*

A nurse is performing triage in the emergency department. Which patient should the nurse see first? 18-year-old patient with type 1 diabetes mellitus who has a 4-cm laceration on right leg 32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort 56-year-old patient with substernal chest pain who is diaphoretic with shortness of breath 78-year-old patient with right hip fracture who is confused; blood pressure is 98/62 mm Hg

*32-year-old patient with drug overdose who is unresponsive with a poor respiratory effort*

Which patient is at greatest risk for sudden cardiac death? A 42-year-old white woman with hypertension and dyslipidemia A 52-year-old African American man with left ventricular failure A 62-year-old obese man with diabetes mellitus and high cholesterol A 72-year-old Native American woman with a family history of heart disease

*A 52-year-old African American man with left ventricular failure*

Which patient should the nurse prepare to transfer to a regional burn center? A 25-year-old pregnant patient with a carboxyhemoglobin level of 1.5% A 39-year-old patient with a partial-thickness burn to the right upper arm A 53-year-old patient with a chemical burn to the anterior chest and neck A 42-year-old patient who is scheduled for skin grafting of a burn wound

*A 53-year-old patient with a chemical burn to the anterior chest and neck*

A patient with a suspected traumatic brain injury has bloody nasal drainage. What observation should cause the nurse to suspect that this patient has a cerebrospinal fluid (CSF) leak? A halo sign on the nasal drip pad Decreased blood pressure and urinary output A positive reading for glucose on a Test-tape strip Clear nasal drainage along with the bloody discharge

*A halo sign on the nasal drip pad*

The nurse prepares to administer temozolomide (Temodar) to a 59-year-old white male patient with a glioblastoma multiforme (GBM) brain tumor. What should the nurse assess before giving the medication? Serum potassium and serum sodium levels Urine osmolality and urine specific gravity Absolute neutrophil count and platelet count Cerebrosprinal fluid (CSF) pressure and cell count

*Absolute neutrophil count and platelet count*

When teaching the patient about the use of range-of-motion (ROM), what explanations should the nurse give to the patient? (select all that apply)? The exercises are the only way to prevent contractures. Active and passive ROM maintain function of body parts. ROM will show the patient that movement is still possible. Movement facilitates mobilization of leaked exudates back into the vascular bed. Active and passive ROM can only be done while the dressings are being changed.

*Active and passive ROM maintain function of body parts.* *ROM will show the patient that movement is still possible.*

An 18-year-old male who fell through the ice on a pond near his farm was admitted to the ED with somnolence. Vital signs are BP 82 mm Hg systolic with Doppler, respirations 9/min, and core temperature of 90° F (32.2° C). The nurse should anticipate which intervention? Active core rewarming Immersion in a hot bath Rehydration and massage Passive external rewarming

*Active core rewarming*

The patient is being dismissed from the hospital after ACS and will be attending rehabilitation. What information does the patient need to be taught about the early recovery phase of rehabilitation? Therapeutic lifestyle changes should become lifelong habits. Physical activity is always started in the hospital and continued at home. Attention will focus on management of chest pain, anxiety, dysrhythmias, and other complications. Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring

*Activity level is gradually increased under cardiac rehabilitation team supervision and with ECG monitoring*

The patient comes to the ED with severe, prolonged angina that is not immediately reversible. The nurse knows that if the patient once had angina related to a stable atherosclerotic plaque and the plaque ruptures, there may be occlusion of a coronary vessel and this type of pain. How will the nurse document this situation related to pathophysiology, presentation, diagnosis, prognosis, and interventions for this disorder? Unstable angina Acute coronary syndrome (ACS) ST-segment-elevation myocardial infarction (STEMI) Non-ST-segment-elevation myocardial infarction (NSTEMI)

*Acute coronary syndrome (ACS)*

For which problem is percutaneous coronary intervention (PCI) most clearly indicated? Chronic stable angina Left-sided heart failure Coronary artery disease Acute myocardial infarction

*Acute myocardial infarction*

The patient has been part of a community emergency response team (CERT) for a tropical storm in Dallas where it has been 100° F (37.7° C) or more for the last 2 weeks. With assessment, the nurse finds hypotension, body temperature of 104° F (40° C), dry and ashen skin, and neurologic symptoms. What treatments should the National Disaster Medical System (NDMS) nurse anticipate (select all that apply)? Administer 100% O2 Immerse in an ice bath. Administer cool IV fluids Cover the patient to prevent chilling. Administer acetaminophen (Tylenol)

*Administer 100% O2* *Administer cool IV fluids*

The nurse is providing emergent care for a 62-year-old man with a possible inhalation injury sustained in a house fire. The patient is anxious and disoriented, and the skin is a cherry red color. Which action should the nurse take first? Administer 100% humidified oxygen Teach the patient deep breathing exercises. Encourage the patient to express his feelings. Assist the patient to a high Fowler's position.

*Administer 100% humidified oxygen*

A 47-year-old man who was lost in the mountains for 2 days is admitted to the emergency department with cold exposure and a core body temperature of 86.6o F (30.3o C). Which action is most appropriate for the nurse to take? Administer warmed IV fluids Position patient under a radiant heat lamp. Place an air-filled warming blanket on the patient. Immerse the extremities in a water bath (102° to 108° F [38.9° to 42.2° C]).

*Administer warmed IV fluids*

An 18-year-old female has been admitted to the emergency department (ED) after ingesting an entire bottle of chewable multivitamins in a suicide attempt. The nurse should anticipate which intervention? Induced vomiting Whole bowel irrigation Administration of activated charcoal Administration of fresh frozen plasma

*Administration of activated charcoal*

There has been a mass casualty incident. Which patient would likely be designated "red" during triage at the site of this occurrence? An individual who is distraught at the violence of the incident An individual who has experienced an open arm fracture from falling debris An individual who is not expected to survive a crushing head and neck wound An individual whose femoral artery has been severed and is bleeding profusely

*An individual whose femoral artery has been severed and is bleeding profusely*

A 19-year-old woman is hospitalized for a frontal skull fracture from a blunt force head injury. Clear fluid is draining from the patient's nose. What action by the nurse is most appropriate? Apply a loose gauze pad under the patient's nose Place the patient in a modified Trendelenburg position. Ask the patient to gently blow the nose to clear the drainage. Gently insert a catheter in the nares and suction the drainage.

*Apply a loose gauze pad under the patient's nose*

The nurse would assess a patient with complaints of chest pain for which clinical manifestations associated with a myocardial infarction (MI) (select all that apply)? Flushing Ashen skin Diaphoresis Nausea and vomiting S3 or S4 heart sounds

*Ashen skin* *Diaphoresis* *Nausea and vomiting* *S3 or S4 heart sounds*

The physician orders intracranial pressure (ICP) readings every hour for a 23-year-old male patient with a traumatic brain injury from a motor vehicle crash. The patient's ICP reading is 21 mm Hg. It is most important for the nurse to take which action? Document the ICP reading in the chart. Determine if the patient has a headache. Assess the patient's level of consciousness Position the patient with head elevated 60 degrees.

*Assess the patient's level of consciousness*

Postoperative care of a patient undergoing coronary artery bypass graft (CABG) surgery includes monitoring for what common complication? Dehydration Paralytic ileus Atrial dysrhythmias Acute respiratory distress syndrome

*Atrial dysrhythmias

Which assessment parameter will the nurse address during the secondary survey of a patient in triage? Blood pressure and heart rate Patency of the patient's airway Neurologic status and level of consciousness Presence or absence of breath sound and quality of breathing

*Blood pressure and heart rate*

The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which change in vital signs would the nurse interpret as a manifestation of increased intracranial pressure (ICP)? Tachypnea Bradycardia Hypotension Narrowing pulse pressure

*Bradycardia*

A patient was admitted to the emergency department (ED) 24 hours earlier with complaints of chest pain that were subsequently attributed to ST-segment-elevation myocardial infarction (STEMI). What complication of MI should the nurse anticipate? Unstable angina Cardiac tamponade Sudden cardiac death Cardiac dysrhythmias

*Cardiac dysrhythmias*

68-year-old man with suspected bacterial meningitis has just had a lumbar puncture in which cerebrospinal fluid was obtained for culture. Which medication should the nurse administer first? Codeine Phenytoin (Dilantin) Ceftriaxone (Rocephin) Acetaminophen (Tylenol)

*Ceftriaxone (Rocephin)*

One week after a thoracotomy, a patient with chest tubes (CTs) to water-seal drainage has an air leak into the closed chest drainage system (CDS). Which patient assessment warrants follow-up nursing interventions? Water-seal chamber has 5 cm of water. No new drainage in collection chamber Chest tube with a loose-fitting dressing Small pneumothorax at CT insertion site

*Chest tube with a loose-fitting dressing*

A mailroom worker was exposed to anthrax (Bacillus anthracis). He is not sure if he inhaled any of it or if it got on his skin because he dropped the envelope when he saw the powder. What treatment(s) should the nurse anticipate? Induce vomiting and administer antitoxin. Patient isolation to prevent spread of virus Immediate vaccinia immune globulin (VIG) Ciprofloxacin (Cipro) to prevent systemic manifestations

*Ciprofloxacin (Cipro) to prevent systemic manifestations*

A 24-year-old male with a gunshot wound to the right side of the chest walks into the emergency department while leaning on another young man. The patient exhibits severe shortness of breath and decreased breath sounds on the right side. Which action should the nurse take immediately? Cover the chest wound with a nonporous dressing taped on three sides Pack the chest wound with sterile saline soaked gauze and tape securely. Stabilize the chest wall with tape and initiate positive pressure ventilation. Apply a pressure dressing over the wound to prevent excessive loss of blood.

*Cover the chest wound with a nonporous dressing taped on three sides*

The nurse is providing teaching to a patient recovering from an MI. How should resumption of sexual activity be discussed? Delegated to the primary care provider Discussed along with other physical activities Avoided because it is embarrassing to the patient Accomplished by providing the patient with written material

*Discussed along with other physical activities*

In caring for a patient with burns to the back, the nurse knows that the patient is moving out of the emergent phase of burn injury when what happens? Serum sodium and potassium increase Serum sodium and potassium decrease. Edema and arterial blood gases improve. Diuresis occurs and hematocrit decreases

*Diuresis occurs and hematocrit decreases*

The patient with leukemia has acute disseminated intravascular coagulation (DIC) and is bleeding. What diagnostic findings should the nurse expect to find? Elevated D-dimers Elevated fibrinogen Reduced prothrombin time (PT) Reduced fibrin degradation products (FDPs)

*Elevated D-dimers *

The nurse is planning care for a patient with partial- and full-thickness skin destruction related to burn injury of the lower extremities. Which interventions should the nurse expect to include in this patient's care ()? (select all that apply)? Escharotomy Administration of diuretics IV and oral pain medications Daily cleansing and debridement Application of topical antimicrobial agent

*Escharotomy* *IV and oral pain medications* *Daily cleansing and debridement* *Application of topical antimicrobial agent*

The nurse is providing care for a patient who has been admitted to the hospital with a head injury and who requires regular neurologic and vital sign assessment. Which assessments will be components of the patient's score on the Glasgow Coma Scale (GCS) (select all that apply)? Judgment Eye opening Abstract reasoning Best verbal response Best motor response Cranial nerve function

*Eye opening* *Best verbal response* *Best motor response*

A 20-year-old man is admitted to the emergency department after a motor vehicle crash with suspected abdominal trauma. What assessment finding by the nurse is of highest priority? Nausea and vomiting Hyperactive bowel sounds Firmly distended abdomen Abrasions on all extremities

*Firmly distended abdomen*

The patient in the emergent phase of a burn injury is being treated for pain. What medication should the nurse anticipate using for this patient? SQ tetanus toxoid IV morphine sulfate IM hydromorphone (Dilaudid) PO oxycodone and acetaminophen (Percocet)

*IV morphine sulfate*

A patient has a systemic blood pressure of 120/60 and an ICP of 24 mm Hg. After calculating the patient's cerebral perfusion pressure (CPP), how does the nurse interpret the results? High blood flow to the brain Normal intracranial pressure Impaired blood flow to the brain Adequate autoregulation of blood flow

*Impaired blood flow to the brain*

A patient experienced sudden cardiac death (SCD) and survived. What should the nurse expect to be used as preventive treatment for the patient? External pacemaker An electrophysiologic study (EPS) Medications to prevent dysrhythmias Implantable cardioverter-defibrillator (ICD)

*Implantable cardioverter-defibrillator (ICD)*

The nurse assesses the right femoral artery puncture site as soon as the patient arrives after having a stent inserted into a coronary artery. The insertion site is not bleeding or discolored. What should the nurse do next to ensure the femoral artery is intact? Palpate the insertion site for induration. Assess peripheral pulses in the right leg. Inspect the patient's right side and back Compare the color of the left and right legs.

*Inspect the patient's right side and back*

An 82-year-old patient is moving into an independent living facility. What is the best advice the nurse can give to the family to help prevent this patient from being accidently burned in her new home? Cook for her. Stop her from smoking. Install tap water anti-scald devices. Be sure she uses an open space heater

*Install tap water anti-scald devices.*

When caring for a patient with an electrical burn injury, which order from the health care provider should the nurse question? Mannitol 75 gm IV Urine for myoglobulin Lactated Ringer's at 25 mL/hr Sodium bicarbonate 24 mEq every 4 hours

*Lactated Ringer's at 25 mL/hr*

A nurse teaches the emergency department staff about their roles during a disaster with mass casualties. Which primary responsibility should the nurse describe that is expected of all licensed and unlicensed health care staff? Notify local, state, and national authorities. Assist security personnel to patrol the area. Learn the hospital emergency response plan Contact the American Red Cross for assistance.

*Learn the hospital emergency response plan*

In reviewing the chart, which patient assessment is likely to have the greatest impact on this patient's risk of death from the accident? ~Sinus tachycardia with frequent premature ventricular contractions (PVCs) ~Left pupil size 10 cm, not reactive to light ~Pulmonary artery wedge pressure (PAWP)16 mm Hg ~PaO2 108 mm Hg, FIO2 50%, PEEP 5 cm ~Cool extremities, weak peripheral pulses PAWP 16 mm Hg Left pupil 10 cm, not reactive to light Sinus tachycardia with frequent PVCs Cool extremities, weak peripheral pulses

*Left pupil 10 cm, not reactive to light*

The patient in the acute phase of burn care has electrical burns on the left side of her body, type 2 diabetes mellitus, and a serum glucose level of 485 mg/dL. What should be the nurse's priority intervention to prevent a life-threatening complication of hyperglycemia for this burned patient? Replace the blood lost. Maintain a neutral pH. Maintain fluid balance Replace serum potassium.

*Maintain fluid balance*

A male patient is brought into the ED with multiple stab wounds to the legs, one stab wound to the left abdomen, and gang tattoos on both arms. He refused to identify his attacker and then loses consciousness. Police identify him as the assailant in the fatal stabbing of another man. What is the nurse's priority? Guard locked access doors. Maintain patient safety from revenge. Maintain personal and work place safety Attain open patient airway and breathing.

*Maintain personal and work place safety* .

A male patient suffered a diffuse axonal injury from a traumatic brain injury (TBI). He has been maintained on IV fluids for 2 days. The nurse seeks enteral feeding for this patient based on what rationale? Free water should be avoided. Sodium restrictions can be managed. Dehydration can be better avoided with feedings. Malnutrition promotes continued cerebral edema

*Malnutrition promotes continued cerebral edema*

What nursing intervention should be implemented in the care of a patient who is experiencing increased ICP? Monitor fluid and electrolyte status carefully Position the patient in a high Fowler's position. Administer vasoconstrictors to maintain cerebral perfusion. Maintain physical restraints to prevent episodes of agitation.

*Monitor fluid and electrolyte status carefully*

During the care of the patient with a burn in the acute phase, which new interventions should the nurse expect to do after the patient progressed from the emergent phase? Begin IV fluid replacement. Monitor for signs of complications. Assess and manage pain and anxiety. Discuss possible reconstructive surgery.

*Monitor for signs of complications.*

The nurse is planning to change the dressing that covers a deep partial-thickness burn of the right lower leg. Which prescribed medication should the nurse administer to the 70-year-old female patient 30 minutes before the scheduled dressing change? Morphine sulfate Sertraline (Zoloft) Zolpidem (Ambien) Enoxaparin (Lovenox)

*Morphine sulfate*

The ambulance reports that they are transporting a patient to the ED who has experienced a full-thickness thermal burn from a grill. What manifestations should the nurse expect? Severe pain, blisters, and blanching with pressure Pain, minimal edema, and blanching with pressure Redness, evidence of inhalation injury, and charred skin No pain, waxy white skin, and no blanching with pressure

*No pain, waxy white skin, and no blanching with pressure*

A 74-year-old man with a history of prostate cancer and hypertension is admitted to the emergency department with substernal chest pain. Which action will the nurse complete before administering sublingual nitroglycerin? Administer morphine sulfate IV. Auscultate heart and lung sounds. Obtain a 12-lead electrocardiogram (ECG) Assess for coronary artery disease risk factors.

*Obtain a 12-lead electrocardiogram (ECG)*

When planning emergent care for a patient with a suspected MI, what should the nurse anticipate administrating? Oxygen, nitroglycerin, aspirin, and morphine Oxygen, furosemide (Lasix), nitroglycerin, and meperidine Aspirin, nitroprusside (Nipride), dopamine (Intropin), and oxygen Nitroglycerin, lorazepam (Ativan), oxygen, and warfarin (Coumadin)

*Oxygen, nitroglycerin, aspirin, and morphine*

The nurse is examining the ECG of a patient who has just been admitted with a suspected MI. Which ECG change is most indicative of prolonged or complete coronary occlusion? Sinus tachycardia Pathologic Q wave Fibrillatory P waves Prolonged PR interva

*Pathologic Q wave*

Which guideline for the assessment of intimate partner violence (IPV) should the emergency nurse follow? Patients should be routinely screened for family and IPV Patients whom the nurse deems high risk should be assessed for IPV. All female patients and patients under 18 should be assessed for IPV. Patients should be assessed for IPV provided corroborating evidence exists.

*Patients should be routinely screened for family and IPV*

The nurse is caring for a patient with superficial partial-thickness burns of the face sustained within the last 12 hours. Upon assessment the nurse would expect to find which manifestation? Blisters Reddening of the skin Destruction of all skin layers Damage to sebaceous glands

*Reddening of the skin*

The patient received a cultured epithelial autograft (CEA) to the entire left leg. What should the nurse include in the discharge teaching for this patient? Sit or lay in the position of comfort. Wear a pressure garment for 8 hours each day. Refer the patient to a counselor for psychosocial support. Use the sun to increase the skin color on the healed areas.

*Refer the patient to a counselor for psychosocial support.*

The nurse assesses a patient for signs of meningeal irritation and observes for nuchal rigidity. What indicates the presence of this sign of meningeal irritation? Tonic spasms of the legs Curling in a fetal position Arching of the neck and back Resistance to flexion of the neck

*Resistance to flexion of the neck*

A patient has sought care 3 days after experiencing a series of tick bites. Which manifestation would indicate that a patient is experiencing tick paralysis? Respiratory distress Aggression and frequent falls Decreased level of consciousness Fever and necrosis at the bite sites

*Respiratory distress*

The nurse is caring for a 34-year-old male patient who sustained a deep partial thickness burn to the anterior chest area during a workplace accident 6 hours ago. Which assessment findings would the nurse identify as congruent with this type of burn? Skin is hard with a dry, waxy white appearance. Skin is shiny and red with clear, fluid-filled blisters Skin is red and blanches when slight pressure is applied. Skin is leathery with visible muscles, tendons, and bones.

*Skin is shiny and red with clear, fluid-filled blisters*

Magnetic resonance imaging (MRI) has revealed the presence of a brain tumor in a patient. The nurse should recognize that the patient will most likely need which treatment modality? Surgery Chemotherapy Radiation therapy Biologic drug therapy

*Surgery*

A patient with a burn inhalation injury is receiving albuterol (Ventolin) for bronchospasm. What is the most important adverse effect of this medication for the nurse to manage? GI distress Tachycardia Restlessness Hypokalemia

*Tachycardia*

In planning long-term care for a patient after a craniotomy, what must the nurse include when teaching the patient, family, and caregiver? Seizure disorders may occur in weeks or months. The family will be unable to cope with role reversals. There are often residual changes in personality and cognition Referrals will be made to eliminate residual deficits from the damage.

*There are often residual changes in personality and cognition*

The nurse is caring for a 46-year-old female patient during the first 12 hours after a thermal burn injury. She weighed 71 kg on admission to the burn unit. Which outcomes if observed by the nurse would indicate adequate fluid resuscitation? (select all that apply) Urine output is 80 mL/hour Heart rate is 86 beats/minute Urine specific gravity is 1.025 Mean arterial pressure is 54 mm Hg. Systolic blood pressure is 88 mm Hg.

*Urine output is 80 mL/hour* *Heart rate is 86 beats/minute* *Urine specific gravity is 1.025*

he patient with increased ICP from a brain tumor is being monitored with a ventriculostomy. What nursing intervention is the priority in caring for this patient? Administer IV mannitol (Osmitrol). Ventilator use to hyperoxygenate the patient Use strict aseptic technique with dressing changes Be aware of changes in ICP related to leaking CSF.

*Use strict aseptic technique with dressing changes*

The nurse is caring for a patient admitted for evaluation and surgical removal of a brain tumor. The nurse will plan interventions for this patient based on knowledge that brain tumors can lead to which complications (select all that apply)? Vision loss Cerebral edema Pituitary dysfunction Parathyroid dysfunction Focal neurologic deficits

*Vision loss* *Cerebral edema* *Pituitary dysfunction* *Focal neurologic deficits*

A 52-year-old male patient has received a bolus dose and an infusion of alteplase (Activase) for an ST-segment elevation myocardial infarction (STEMI). To determine the effectiveness of this medication, the nurse should assess the patient for the presence of chest pain blood in the urine or stool. tachycardia with hypotension. decreased level of consciousness.

*presence of chest pain*

The nurse is caring for a patient with partial- and full-thickness burns to 65% of the body. When planning nutritional interventions for this patient, what dietary choices should the nurse implement? Full liquids only Whatever the patient requests High-protein and low-sodium foods High-calorie and high-protein foods

High-calorie and high-protein foods

A nurse is caring for a patient with second- and third-degree burns to 50% of the body. The nurse prepares fluid resuscitation based on knowledge of the Parkland (Baxter) formula that includes which recommendation? The total 24-hour fluid requirement should be administered in the first 8 hours. One half of the total 24-hour fluid requirement should be administered in the first 8 hours. One third of the total 24-hour fluid requirement should be administered in the first 4 hours. One half of the total 24-hour fluid requirement should be administered in the first 4 hours.

One half of the total 24-hour fluid requirement should be administered in the first 8 hours.

A patient is admitted to the emergency department with first- and second-degree burns after being involved in a house fire. Which assessment findings would alert you to the presence of an inhalation injury? (select all that apply)? Singed nasal hair Generalized pallor Painful swallowing Burns on the upper extremities History of being involved in a large fire

Singed nasal hair* *Generalized pallor* *Painful swallowing* *History of being involved in a large fire*