Quiz 3 review
the nurse is monitoring the fluid replacement of a client who has sustained burns. the nurse should administer which of the following fluids in the first 24 hrs following a burn injury
LRS
a nurse in a community in a health care setting is caring for who reports a headache and a stiff neck. which of the following actions should the nurse take first?
evaluate a client's neurologic status
a nurse is caring for a client who has a chest tube in place to closed sub chest drainage system. which of the following finding should indicate to the nurse the client's lung has re expanded
no fluctuations in the water seal chamber
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
a large incisions made in the eschar to improve circulation
a nurse in the ED is caring for a client who as a 30% burn injury to her lower extremity. which of the following interventions should the nurse perform first
administer IV fluids
a patient with chronic heart failure who is taking a diuretic and an ace inhibitor and is in a low sodium diet tell the home health nurse about a 5 lb weight gain in the past 3 days. what is the nurses priority action
assess for manifestation of acute heart failure
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? a. A large air leak in the water-seal chamber b. 400 mL of blood in the collection chamber c. Complaint of pain with each deep inspiration d. Subcutaneous emphysema at the insertion site
b. 400 mL of blood in the collection chamber
the nurse is caring for a client who has a mild TBI. which of the following manifestations should the nurse immediately report to the provider
change in GCS score from 13 to 11
a nurse in the ED is reviewing the medical record for the client who has an extensive burn injury. which of the following lab results should the nurse expect?
hyperkalemia - results from muscle damage
A patient has just arrived on the PACU after a thyroidectomy. which of the following is important to communicate to the surgeon
increased swelling in neck
a nurse in a ED is caring for client who has a deep partial and full thickness burns to his chest, abdomen and upper arms. what is the nurse priority intervention for this client during the resuscitation of phase of injury
maintain the airway
which information will the nurse monitor to determine the effectiveness of prescribed calcium carbonate for the patient with CKD
phosphate
a nurse is assessing a client who has DI. which of the following finding is a manifestation of the diagnosis hypertension bounding peripheral pulses hyperglycemia tachycardia
tachycardia
a nurse in the emergency department is caring for a client following an automobile crash in which the client was unrestrained and thrown from the vehicle. when assessing the client, the nurse notes clear fluid draining from the nose. which of the following interventions should the nurse take?
take a piece of gauze and do a halo test
which information about a patient with a lumbar vertebral fracture should the nurse immediately report to the provider
the patient has been incontinent of urine and stool
a nurse is admitting a young adult client who has suspected bacterial meningitis. the nurse should closely monitor the client for ICP as indicated for which of the following findings.
widened pulse pressure
The nurse obtains the following data when assessing a patient who experienced an ST-segment-elevation myocardial infarction (STEMI) 2 days previously. Which information is most important to report to the health care provider? a. The troponin level is elevated. b. The patient denies having a heart attack. c. Bilateral crackles in the mid-lower lobes. d. Occasional premature atrial contractions (PACs).
c. Bilateral crackles in the mid-lower lobes.
After endotracheal suctioning, the nurse notes that the intracranial pressure for a patient with a traumatic head injury has increased from 14 to 17 mm Hg. Which action should the nurse take first? a.Document the increase in intracranial pressure. b.Ensure that the patient's neck is in neutral position. c. Notify the health care provider about the change in pressure. d. Increase the rate of the prescribed propofol (Diprivan) infusion.
b.Ensure that the patient's neck is in neutral position.
On admission to the burn unit, a patient with an approximate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 58%, Hgb 18.2 mg/dL (172 g/L), serum K+ 4.9 mEq/L (4.8 mmol/L), and serum Na+ 135 mEq/L (135 mmol/L). Which action will the nurse anticipate taking now? a. Monitor urine output every 4 hours. b. Continue to monitor the laboratory results. c. Increase the rate of the ordered IV solution. d. Type and crossmatch for a blood transfusion.
c. Increase the rate of the ordered IV solution. - Hct and Hgb are too high
a nurse is assessing a client who has a concussion from a sports injury. which of the following manifestations should the nurse expect
sensitivity to light - photophobia
a nurse is assessing a patient following a head injury and a brief loss of consciousness. which of the following finding should the nurse report to the provider
small drops of clear fluid in the ear
a nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. the nurse obtains a BP of 210/108 and suspect a client is experiencing autonomic dysreflexia. which of the following actions should the nurse do first
place the client in a high fowlers position
the patient who has a suspected epidural hematoma is admitted to the ED. which action will the nurse expect to take
prepare the patient for a craniotomy
