Assessment 2 review

The nurse is reviewing laboratory results on a patient who had a large burn 48 hours ago. Which result requires priority action by the nurse Hematocrit 53% ​ Serum sodium 147 mEq/L ​ Serum potassium 6.1 mEq/L​ Blood urea nitrogen 37 mg/dL

Serum potassium 6.1 mEq/L​

Which hemodynamic parameter is most appropriate for the nurse to monitor to determine the effectiveness of medications given to a patient to reduce left ventricular afterload Mean arterial pressure (MAP) ​ Systemic vascular resistance (SVR) ​ Pulmonary vascular resistance (PVR) ​ Pulmonary artery wedge pressure (PAWP)

Systemic vascular resistance (SVR) ​

A patient who is being treated for stage IV lung cancer tells the nurse about new-onset back pain. Which action should the nurse take first Give the patient the prescribed PRN opioid. ​ Assess for sensation and strength in the legs. ​ Notify the health care provider about the symptoms. ​ Teach the patient how to use relaxation to reduce pain

Assess for sensation and strength in the legs. ​

What is the definition of preload Systemic vascular resistance​ Pulmonary vascular resistance​ End diastolic volume in the ventricle ​ Ease of contraction of the ventricle ​

End diastolic volume in the ventricle

When assessing a patient who is a construction worker who had chemical burns on his right foot from cement that seeped into a hole in his boot, the nurse notes that the skin is dry, pale, hard skin in some areas and black in others. The patient states that the burn is not painful. What term would the nurse use to document the burn depth First-degree skin destruction ​ Full-thickness skin destruction​ Deep partial-thickness skin destruction ​ Superficial partial-thickness skin destruction

Full-thickness skin destruction​

The nurse assesses a patient with non-Hodgkin's lymphoma who is receiving an infusion of rituximab (Rituxan). Which assessment finding would require the most rapid action by the nurse​ Shortness of breath ​ Temperature 100.2° F (37.9° C) ​ Shivering and complaint of chills ​ Generalized muscle aches and pains

Rituximab (Rituxan) is a monoclonal antibody. Shortness of breath should be investigated rapidly because anaphylaxis is a possible reaction to monoclonal antibody administration. The nurse will need to rapidly take actions such as stopping the infusion, assessing the patient further, and notifying the health care provider. The other findings will also require action by the nurse, but are not indicative of life-threatening complications

Eight hours after a thermal burn covering 50% of a patient's total body surface area (TBSA) the nurse assesses the patient. Which information would be a priority to communicate to the health care provider​ Blood pressure is 95/48 per arterial line. ​ Serous exudate is leaking from the burns. ​ Cardiac monitor shows a pulse rate of 108. ​ Urine output is 20 mL per hour for the past 2 hours

Urine output is 20 mL per hour for the past 2 hours The urine output should be at least 0.5 to 1.0 mL/kg/hr during the emergent phase, when the patient is at great risk for hypovolemic shock. The nurse should notify the health care provider because a higher IV fluid rate is needed. BP during the emergent phase should be greater than 90 mm Hg systolic and the pulse rate should be less than 120 beats/min. Serous exudate from the burns is expected during the emergent phase

After treatment with the chemotherapeutic agent cyclophosphamide (Cytoxan), a breast cancer patient's lab results show the patient is hyponatremic with a serum osmolality lower than urine osmolality. The nurse suspects:​ a) tumor lysis syndrome.​ b) syndrome of inappropriate ADH (SIADH).​ c) cardiac tamponade​ d) superior vena cava syndrome

b) syndrome of inappropriate ADH (SIADH).