critical life threatening EAQ

Which are the priority nursing actions related to breathing assessments in a primary survey during an emergency assessment? Select all that apply. One, some, or all responses may be correct.

having suction available giving supplemental oxygen

Which health concern has the highest priority for the nurse to monitor for after removing clothing from a client with burn trauma?

hypothermia

A client is admitted to the hospital with partial- and full-thickness burns of the chest and face sustained while trying to extinguish a brush fire. Which concern is the nurse's priority?

inadequate gas exchange caused by smoke inhalation

The nurse is working as a triage nurse in the emergency department. Place the clients in the order in which they would receive care.

infant having a seizure woman with acute chest pain man with acute pancreatitis child that needs stitches glucose of 190

Which finding would the nurse expect when assessing a client diagnosed with hypovolemic shock?

oliguria

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?

validating availability of bag valve mask during transfer

The nurse is planning care to prevent deformities and contractures in a client with burns. When would the nurse begin range-of-motion (ROM) exercises?

when vital signs are stable

Which statement by the student nurse requires further teaching about which action would be provided for a client who survived an earthquake and presents with abdominal trauma to the emergency department?

"I should remove an impaled object immediately."

Which statement regarding interventions for clients with inhalation burns shows a nurse needs further education?

"I would immediately calculate the burned surface area with the rule of nines."

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower leg extremity and the anterior portion of the right upper arm. The nurse performs an immediate appraisal of the percentage of body surface area burned using the rule of nines. What percentage of body surface area does the nurse determine is affected? Record the answer to one decimal place. _______%

22.5%

A client receiving a blood transfusion reports itching and difficulty breathing. The heart rate has increased, and the blood pressure is falling. Which type of shock would the nurse suspect the client is experiencing?

Anaphylactic shock

When administering albumin intravenously, which fluid shift would the nurse anticipate?

Interstitial compartment to the intravascular compartment

Which roles would norepinephrine's mechanism of action perform in managing anaphylaxis?

Norepinephrine functions as a peripheral vasoconstrictor

A client is recovering from full-thickness burns, and the nurse provides counseling on how to best meet nutritional needs. Which client food selections indicate to the nurse that the client understands the teaching?

cheeseburger and milk shake

Which finding will the nurse expect when caring for a client who is in hypovolemic shock?

cold skin temp

.Which assessment finding will the nurse expect when caring for a client who has cardiogenic shock?

cold, clammy skin

Which nursing intervention would prevent septic shock in the hospitalized client?

Use aseptic technique during all invasive procedures

Which change in the client's lab results indicates that the client is in septic shock?

an increased serum lactate level

Which action would be the nurse's first priority when receiving a client with major burns?

assessing airway patency

Which disaster triage tag would the nurse apply to the group of clients who have extensive full-thickness body burns and severe head trauma after an apartment building fire and clients who require mechanical ventilation for survival?

black tag

A client who experienced extensive burns is receiving intravenous fluids to replace fluid loss. The nurse would monitor for which initial symptom of fluid overload?

crackles in lungs

The nurse is caring for a client with hemodynamically stable sepsis who complains of abdominal pain. Which of these primary health care provider prescriptions would the nurse do first?

draw peripheral blood cultures from two different sites

Which triage tag and client condition pair is correct?

major injuries with yellow tag

A 4-month-old infant is brought to the emergency department after 2 days of diarrhea. The infant is listless and has sunken eyeballs, a depressed anterior fontanel, and poor tissue turgor. Breathing is deep, rapid, and unlabored. Stools are liquid and there has been no obvious urine output. Which problem would the nurse be concerned about?

metabolic acidosis

When caring for a client in late hypovolemic shock, which complication will the nurse anticipate?

metabolic acidosis

Which intervention would the nurse use for a client with full-thickness burns to the chest and anterior right arm? Select all that apply. One, some, or all responses may be correct.

monitor vital signs cut of clothing insert urinary catheter remove jewelry establish IV access

Which clinical findings would the nurse expect when assessing a client who has cardiogenic shock? Select all that apply. One, some, or all responses may be correct.

pallor agitation tachycardia narrow pulse pressure

While conducting triage under mass casualty conditions, which tag would the nurse use for a client who is experiencing hypovolemic shock due to a penetrating wound?

red tag

Which clinical manifestation is associated with hypernatremia in burns?

seizures

The nurse is caring for a client with severe burns 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet?

tea