S4 Unit 5 questions 2

An emergency room nurse cares for a client admitted with a 50% burn injury at 10:00 this morning. The client weighs 90 kg. Using the Parkland formula, calculate the rate at which the nurse should infuse intravenous fluid resuscitation when started at noon. (Record your answer using a whole number.) _____ mL/hr

1500 The Parkland formula is 4 mL/kg/% total body surface area burn. This client needs 18,000 mL of fluid during the first 24 hours postburn. Half of the calculated fluid replacement needs to be administered during the first 8 hours after injury, and half during the next 16 hours. This client was burned at 10:00 AM, and fluid was not started until noon. Therefore, 9000 mL must be infused over the next 6 hours at a rate of 1500 mL/hr to meet the criteria of receiving half the calculated dose during the first 8 postburn hours

A nurse cares for a client with burn injuries. Which intervention should the nurse implement to appropriately reduce the client's pain? a. Administer the prescribed intravenous morphine sulfate. b. Apply ice to skin around the burn wound for 20 minutes. c. Administer prescribed intramuscular ketorolac (Toradol). d. Decrease tactile stimulation near the burn injuries.

a

A nurse delegates hydrotherapy to an unlicensed assistive personnel (UAP). Which statement should the nurse include when delegating this activity? a. "Keep the water temperature constant when showering the client." b. "Assess the wound beds during the hydrotherapy treatment." c. "Apply a topical enzyme agent after bathing the client." d. "Use sterile saline to irrigate and clean the client's wounds."

a

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

a A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign.

A client who has a herniated disk is being discharged after a percutaneous endoscopic discectomy. Which postprocedure instructions does the nurse provide before discharge? a. "You should begin an exercise routine which includes walking every day." b. "You must sleep in a supine position until the bandage is removed." c. "You may feel numbness or tingling in the legs for 24 hours." d. "You will need to wear a lumbar brace for 1 week."

a After this minimally invasive surgery, clients typically go home the same day or the day after surgery. Clients should be taught to begin the prescribed exercise program immediately after discharge, which includes walking every day. The client should not be restricted to one sleeping position.

The intensive care nurse is educating the spouse of a client who is being treated for shock. The spouse states, "The doctor said she has shock. What is that?" What is the nurse's best response? a. "Shock occurs when oxygen to the body's tissues and organs is impaired." b. "Shock is a serious condition, but it is not a life-threatening emergency." c. "Shock progresses slowly and can be stopped by the body's normal compensation." d. "Shock is a condition that affects only specific body organs like the kidneys."

a Any problem that impairs oxygen delivery to tissues and organs can start the syndrome of shock and lead to a life-threatening emergency. Shock represents the "whole-body response," affecting all organs in a predictable sequence. Compensation mechanisms attempt to maintain homeostasis and deliver necessary oxygen to organs but eventually will fail without reversal of the cause of shock, resulting in death.

The nurse assesses a client in the burn unit after the client was repositioned by the nursing assistant. The nurse intervenes after finding the client repositioned in what manner? a. Supine with one pillow behind the head b. Semi-Fowler's position with arms elevated c. Wrists extended to 30 degrees in a splint d. A towel roll placed under the neck or shoulder

a Clients must be positioned to prevent contractures. The function that would be disrupted by a contracture to the posterior neck is flexion. The client should not be positioned with a pillow behind the head; this would increase flexion. The nurse must intervene and position the client so that neck flexion does not occur. The other options include proper positioning techniques that will help prevent contracture

Which nursing intervention is likely to be most helpful in providing adequate nutrition while a client is recovering from a thermal burn injury? a. Allowing the client to eat whenever he or she wants b. Beginning parenteral nutrition high in calories c. Including 3000 kcal/day of calories with meals d. Providing a low-protein, high-fat diet

a Clients should request food whenever they think they can eat, not just according to the hospital's standard meal schedule. The nurse needs to work with a dietitian to provide a high-calorie, high-protein diet to help with wound healing. Clients who can eat solid foods should ingest as many calories as possible; they may need as many as 5000 kcal/day. Specific caloric requirements can be determined by the dietitian. Parenteral nutrition may be given as a last resort because it is invasive and can lead to infectious and metabolic complications

The nurse is caring for multiple clients in the emergency department. The client with which condition is at highest risk for distributive shock? a. Severe head injury from a motor vehicle accident b. Diabetes insipidus from polycystic kidney disease c. Ischemic cardiomyopathy from severe coronary artery disease d. Vomiting of blood from a gastrointestinal ulcer

a Distributive shock is the type of shock that occurs when blood volume is not lost from the body but is distributed to the interstitial tissues, where it cannot circulate and deliver oxygen. Neurally-induced distributive shock may be caused by pain, anesthesia, stress, spinal cord injury, or head trauma.

The nurse has been teaching a client about skin grafting procedures. What statement indicates that the client needs further education about allografts? a. "Because the graft is my own skin, there is no chance it won't 'take.'" b. "For a few days after surgery, the donor sites will be painful." c. "I will have some scarring in the area where the skin is removed." d. "I am still at risk for infection after the procedure until the burn heals."

a Factors other than tissue type, such as circulation and infection, influence whether and how well a graft will work. The client should be prepared for the possibility that not all grafting procedures will be successful. Donor sites will be painful after surgery, scarring can occur in the area where skin is removed for grafting, and the client is still at risk for infection.

A nurse administers topical gentamicin sulfate (Garamycin) to a client's burn injury. Which laboratory value should the nurse monitor while the client is prescribed this therapy? a. Creatinine b. Red blood cells c. Sodium d. Magnesium

a Gentamicin is nephrotoxic, and sufficient amounts can be absorbed through burn wounds to affect kidney function. Any client receiving gentamicin by any route should have kidney function monitored. Topical gentamicin will not affect the red blood cell count or the sodium or magnesium levels.

A client who is admitted after a thermal burn injury has the following vital signs: blood pressure, 70/40; heart rate, 140 beats/min; and respiratory rate, 25 breaths/min. He is pale, and it is difficult to find pedal pulses. Which action does the nurse take first? a. Begin intravenous fluid resuscitation. b. Check pulses with a Doppler device. c. Obtain a complete blood count (CBC). d. Obtain an electrocardiogram (ECG).

a Hypovolemic shock is a common cause of death in the emergent phase of clients with serious injury. Fluids can treat this problem. ECG and CBC will be taken to ascertain whether a cardiac or bleeding problem is causing these vital signs. However, these are not actions that the nurse would take immediately. Checking pulses would indicate perfusion to the periphery, but this is not an immediate nursing action.

Ten hours after a client with 50% burns is admitted, her blood glucose level is 152 mg/dL. What action by the nurse is most appropriate? a. Document the finding. b. Obtain a family history for diabetes. c. Repeat the glucose measurement. d. Stop IV fluids containing dextrose.

a Neural and hormonal compensation to the stress of the burn injury in the emergent phase increases liver glucose production and release. An acute rise in the blood glucose level is an expected client response and is helpful in the generation of energy needed for the increased metabolism that accompanies this trauma. A family history of diabetes could place her at higher risk for the disease, but this is not a priority at this time. The glucose level is not high enough to warrant retesting. The cause of her elevated blood glucose is not the IV fluid

A client in shock is apprehensive and slightly confused. What action by the nurse is best? a. Offer to remain with the client for awhile. b. Prepare to administer antianxiety medication. c. Raise all four siderails on the client's bed. d. Tell the client everything possible is being done.

a The nurse's presence will be best to reassure this client. Antianxiety medication is not warranted as this will lower the client's blood pressure. Using all four siderails on a hospital bed is considered a restraint in most facilities, although the nurse should ensure the client's safety.

The nurse has provided instruction on the facial pressure garment to a client with facial burns. Which statement indicates that the client understands these instructions? a. "My scars should be less severe with the use of this mask." b. "The mask will help protect my skin from sun damage." c. "This treatment will help prevent infection." d. "Using the mask will keep scars from being permanent."

a The purpose of wearing the pressure garment over burn injuries for up to 1 year is to prevent hypertrophic scarring and contractures from forming. Scars will still be present. Although the mask does provide protection of sensitive, newly healed skin and grafts from sun exposure, this is not the purpose of wearing the mask. The pressure garment will not alter the risk for infection.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

a These manifestations indicate Cushing's syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP

A nurse cares for a client with burn injuries during the resuscitation phase. Which actions are priorities during this phase? (Select all that apply.) a. Administer analgesics. b. Prevent wound infections. c. Provide fluid replacement. d. Decrease core temperature. e. Initiate physical therapy.

abc Nursing priorities during the resuscitation phase include securing the airway, supporting circulation and organ perfusion by fluid replacement, keeping the client comfortable with analgesics, preventing infection through careful wound care, maintaining body temperature, and providing emotional support.

The nurse caring frequently for older adults in the hospital is aware of risk factors that place them at a higher risk for shock. For what factors would the nurse assess? (Select all that apply.) a. Altered mobility/immobility b. Decreased thirst response c. Diminished immune response d. Malnutrition e. Overhydration

abcd

A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Tape a halo wrench to the client's vest. b. Assess the pin sites for signs of infection. c. Loosen the pins when sleeping. d. Decrease the client's oral fluid intake. e. Assess the chest and back for skin breakdown.

abe A special halo wrench should be taped to the client's vest in case of a cardiopulmonary emergency. The nurse should assess the pin sites for signs of infection or loose pins and for complications from the halo. The nurse should also increase fluids and fiber to decrease bowel straining and assess the client's chest and back for skin breakdown from the halo vest.

A nurse plans care for a client with burn injuries. Which interventions should the nurse include in this client's plan of care to ensure adequate nutrition? (Select all that apply.) a. Provide at least 5000 kcal/day. b. Start an oral diet on the first day. c. Administer a diet high in protein. d. Collaborate with a registered dietitian. e. Offer frequent high-calorie snacks.

acde A client with a burn injury needs a high-calorie diet, including at least 5000 kcal/day and frequent high-calorie snacks. The nurse should collaborate with a registered dietitian to ensure the client receives a high-calorie and high-protein diet required for wound healing. Oral diet therapy should be delayed until GI motility resumes

The nurse assesses a client admitted for rehabilitation. The client has generalized weakness and needs assistance with activities of daily living. Which exercise should the nurse implement? a. Passive range of motion b. Active range of motion c. Resistive range of motion d. Aerobic exercise

b

The nurse is assessing a client who has shock. Which laboratory value indicates that the client is at risk for acidosis? a. Decreased serum creatinine b. Increased serum lactic acid c. Increased urine specific gravity d. Decreased partial pressure of arterial carbon dioxide

b

The nurse is conducting a home safety class. It is most important for the nurse to include which information in the teaching plan? a. Have an escape route everyone knows about. b. Keep a smoke detector in each bedroom. c. Use space heaters instead of gas heaters. d. Use carbon monoxide detectors in the garage.

b

A nurse assesses a client admitted with deep partial-thickness and full-thickness burns on the face, arms, and chest. Which assessment finding should alert the nurse to a potential complication? a. Partial pressure of arterial oxygen (PaO2) of 80 mm Hg b. Urine output of 20 mL/hr c. Productive cough with white pulmonary secretions d. Core temperature of 100.6° F (38° C)

b A significant loss of fluid occurs with burn injuries, and fluids must be replaced to maintain hemodynamics. If fluid replacement is not adequate, the client may become hypotensive and have decreased perfusion of organs, including the brain and kidneys. A low urine output is an indication of poor kidney perfusion. The other manifestations are not complications of burn injuries.

The nurse is assessing a client at risk for shock. The client's systolic blood pressure is 20 mm Hg lower than baseline. Which intervention does the nurse perform first? a. Increase the IV fluid rate. b. Administer oxygen. c. Notify the health care provider. d. Place the client in high Fowler's position.

b Administration of oxygen for any type of shock is appropriate to help reduce potential damage from tissue hypoxia. The other interventions should be completed after oxygen is administered.

The nurse is assessing a client with a spinal cord injury at the T5 level. Which clinical manifestation alerts the nurse to the presence of a complication of this injury? a. Rhinorrhea and epiphora b. Fever and cough c. Agitation and restlessness d. Hip and knee pain

b Clients with injuries at or above the T6 vertebra are especially at risk for respiratory complications caused by impaired intercostal muscles. The development of fever and cough should alert the nurse to the possibility of pneumonia. The other manifestations are not related to complications from this type of injury.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95° F (35° C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

b In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria.

A client has severe burns around the right hip. Which position does the nurse instruct the nursing assistant to use to maintain maximum function of this joint? a. Hip maintained in 30-degree flexion b. Hip at zero flexion with leg flat c. Knee flexed at 30-degree angle d. Leg abducted with foam wedge

b Maximum function for ambulation occurs when the hip and the leg are maintained at full extension with neutral rotation. Although the client does not have to spend 24 hours in this position, he or she should be in this position (in bed or standing) longer than with the hip in any degree of flexion.

An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? a. Intrathecal baclofen (Lioresal) b. Methylprednisolone (Medrol) c. Atropine sulfate d. Epinephrine (Adrenalin)

b Methylprednisolone (Medrol) should be given within 8 hours of the injury. Clients who receive this therapy usually show improvement in motor and sensory function.

A nurse is caring for a client after surgery. The client's respiratory rate has increased from 12 to 18 breaths/min and the pulse rate increased from 86 to 98 beats/min since they were last assessed 4 hours ago. What action by the nurse is best? a. Ask if the client needs pain medication. b. Assess the client's tissue perfusion further. c. Document the findings in the client's chart. d. Increase the rate of the client's IV infusion.

b Signs of the earliest stage of shock are subtle and may manifest in slight increases in heart rate, respiratory rate, or blood pressure. Even though these readings are not out of the normal range, the nurse should conduct a thorough assessment of the client, focusing on indicators of perfusion. The client may need pain medication, but this is not the priority at this time. Documentation should be done thoroughly but is not the priority either.

A client has experienced an electrical injury of the lower extremities. Which priority assessment data should be obtained from this client? a. Range of motion in all extremities b. Heart rate, rhythm, and electrocardiogram (ECG) c. Respiratory rate and pulse oximetry d. Orientation to time, place, and person

b The airway is not at any particular risk with this injury. Therefore, respiratory rate and pulse oximetry are not priority assessments. Electrical current travels through the body from the entrance site to the exit site and can seriously damage all tissues between the two sites. Early cardiac damage from electrical injury includes irregular heart rate and rhythm, and ECG changes.

A client has a large burned area on the right arm. The burned area appears pink, has blisters, and is very painful. How does the nurse categorize this injury? a. Full thickness b. Partial thickness superficial c. Partial thickness deep d. Superficial

b The characteristics of the wound meet the criteria for a superficial partial-thickness injury: color that is pink or red; blisters; and pain. Blisters are not seen with full-thickness and superficial burns and are rarely seen with deep partial-thickness burns. Deep partial-thickness burns appear red to white

The nurse is administering prescribed sodium nitroprusside (Nipride) intravenously to a client who has shock. Which nursing intervention is a priority when administering this medication? a. Ask if the client has chest pain every 30 minutes. b. Assess the client's blood pressure every 15 minutes. c. Monitor the client's urinary output every hour. d. Observe the client's extremities every 4 hours.

b The client receiving sodium nitroprusside should have his or her blood pressure assessed every 15 minutes. Higher doses can cause systemic vasodilation and can increase shock. The nurse should monitor the client's pain, urinary output, and extremities, but these assessments do not directly relate to the nitroprusside infusion.

A nurse cares for a client with burn injuries from a house fire. The client is not consistently oriented and reports a headache. Which action should the nurse take? a. Increase the client's oxygen and obtain blood gases. b. Draw blood for a carboxyhemoglobin level. c. Increase the client's intravenous fluid rate. d. Perform a thorough Mini-Mental State Examination.

b These manifestations are consistent with moderated carbon monoxide poisoning. This client is at risk for carbon monoxide poisoning because he or she was in a fire in an enclosed space. The other options will not provide information related to carbon monoxide poisoning

A nurse plans care for a client with lower back pain from a work-related injury. Which intervention should the nurse include in this client's plan of care? a. Encourage the client to stretch the back by reaching toward the toes. b. Massage the affected area with ice twice a day. c. Apply a heating pad for 20 minutes at least four times daily. d. Advise the client to avoid warm baths or showers.

c Heat increases blood flow to the affected area and promotes healing of injured nerves. Stretching and ice will not promote healing, and there is no need to avoid warm baths or showers.

A client suffered a 45% total body surface area (TBSA) burn and was intubated. Twelve hours later, bowel sounds were absent in all four abdominal quadrants. Which is the nurse's best action? a. Administer a laxative. b. Document the finding. c. Prepare to insert a nasogastric (NG) tube. d. Reposition the client on the right side.

c Decreased or absent peristalsis is a frequent response during the emergent phase of burn injury as a result of neural and hormonal compensation to the stress of injury. The result is often a paralytic ileus. Clients who have burns greater than 25% TBSA or who are intubated generally need to have an NG tube inserted

The nurse is monitoring a client in hypovolemic shock who has been placed on a dopamine hydrochloride (Intropin) drip. Which manifestation is a desired response to this medication? a. Decrease in blood pressure b. Increase in heart rate c. Increase in cardiac output d. Decrease in mean arterial pressure

c Dopamine hydrochloride causes vasoconstriction that in turn increases cardiac output and mean arterial pressure, thereby improving tissue perfusion and oxygenation. Tachycardia is not a desired response but often occurs as a side effect

An older adult client with burns has a white blood cell count of 10,000/mm3. The client is afebrile with a heart rate of 110 beats/min, a respiratory rate of 20 breaths/min, and blood pressure of 112/68 mm Hg. The client's wound is pale, and edema is noted in the surrounding tissues. Which intervention by the nurse is most appropriate? a. Assess the client's skin for signs of adequate perfusion. b. Calculate intake and output ratio for the last 24 hours. c. Prepare to obtain blood and wound cultures. d. Place the client in an isolation room.

c Older clients have a decreased immune response, so they may not exhibit signs that their immune system is actively fighting an infection such as fever or an increased white blood cell count. They also are at higher risk for sepsis arising from a localized wound infection. The wound shows signs of local infection, so the nurse should assess for this and for systemic infection before the client manifests sepsis.

A nurse teaches a client being treated for a full-thickness burn. Which statement should the nurse include in this client's discharge teaching? a. "You should change the batteries in your smoke detector once a year." b. "Join a program that assists burn clients to reintegration into the community." c. "I will demonstrate how to change your wound dressing for you and your family." d. "Let me tell you about the many options available to you for reconstructive surgery."

c Teaching clients and family members to perform care tasks such as dressing changes is critical for the progressive goal toward independence for the client. All of the other options are important in the rehabilitation stage. However, dressing changes have priority.

The nurse is caring for a client in a rehabilitation center. Which test will best assist the nurse in determining the severity of a client's disability? a. Instrumental activities of daily living (IADL) b. Minimum data set (MDS) c. Functional independence measure (FIM) d. Independent living skills test (ILST)

c The FIM attempts to quantify what the person actually does, whatever the diagnosis or impairment. Categories for assessment consist of self-care, sphincter control, mobility, locomotion, communication, and cognition. The functional independence measure is a uniform data set used for outcome data collection in the United States. IADL is a functional assessment tool carried out by numerous members of the interdisciplinary team in the health care setting. The MDS is used to assess nursing home residents in areas of motor ability, sensation, and cognition, as well as overall health status

A nurse reviews the following data in the chart of a client with burn injuries: Bilateral leg burns present with a white and leather-like appearance. No blisters or bleeding present. Client rates pain 2/10 on a scale of 0-10. Based on the data provided, how should the nurse categorize this client's injuries? a. Partial-thickness deep b. Partial-thickness superficial c. Full thickness d. Superficial

c The characteristics of the client's wounds meet the criteria for a full-thickness injury: color that is black, brown, yellow, white, or red; no blisters; minimal pain; and firm and inelastic outer layer. Partial-thickness superficial burns appear pink to red and are painful. Partial-thickness deep burns are deep red to white and painful. Superficial burns are pink to red and are also painful.

The nurse is teaching a client who has an unstable thoracic vertebral fracture and is being treated with immobilization before surgery. Which statement does the nurse include in the client's teaching? a. "You will need to apply an immobilizing brace snugly around your waist when out of bed." b. "You will remain strapped to the transport back board until the surgical room is ready." c. "Keep your spine in alignment by not sitting up, arching your back, or twisting in bed." d. "An incentive spirometer will prevent you from having atelectasis and pneumonia after surgery."

c The client with a thoracic vertebral fracture is at risk for spinal cord injury, especially with flexion, extension, or rotation of the trunk. The client will be moved to a more comfortable bed to wait for surgery and will remain on bedrest. Although teaching about how to use an incentive spirometer is important for surgical clients, the incentive spirometer alone does not prevent atelectasis and pneumonia; it only assists the client to breathe deeply

The nurse provides wound care for a client 48 hours after a burn injury. To achieve the desired outcome of the procedure, which action does the nurse perform first? a. Apply silver sulfadiazine (Silvadene) ointment. b. Cover the area with an elastic wrap. c. Place a synthetic dressing over the area. d. Remove loose nonviable tissue.

d All steps are part of the nonsurgical wound care for clients with burn injuries. The first step in this process consists of removing exudates and necrotic tissue.

A nurse assesses bilateral wheezes in a client with burn injuries inside the mouth. Four hours later the wheezing is no longer heard. Which action should the nurse take? a. Document the findings and reassess in 1 hour. b. Loosen any constrictive dressings on the chest. c. Raise the head of the bed to a semi-Fowler's position. d. Gather appropriate equipment and prepare for an emergency airway.

d Clients with severe inhalation injuries may sustain such progressive obstruction that they may lose effective movement of air. When this occurs, wheezing is no longer heard, and neither are breath sounds. These clients can lose their airways very quickly, so prompt action is needed. The client requires establishment of an emergency airway. Swelling usually precludes intubation. The other options do not address this emergency situation.

A client who has a lower motor neuron injury experiences a flaccid bowel elimination pattern. Which action does the nurse implement to assist in relieving this client's constipation? a. Pouring warm water over the perineum b. Tapping the abdomen from left to right c. Administering daily tap water enemas d. Implementing a consistent daily time for elimination

d For the client with a lower motor neuron injury, the resulting flaccid bowel may require a bowel program for the client, which includes stool softeners, increased fluid intake, a high-fiber diet, and a consistent elimination time. The other interventions do not assist this client.

The nurse is assessing a client who had a discectomy 6 hours ago. Which client complaint requires priority action by the nurse? a. "I am feeling tired." b. "My mouth is so dry." c. "I can't seem to relax and rest." d. "I am unable to urinate."

d Inability to void may indicate damage to the sacral spinal nerves. The other symptoms require the nurse to provide care but are not the priority or a complication of the procedure

The nurse is providing discharge teaching to a client after a lumbar laminectomy. For which complication does the nurse instruct the client to return to the hospital? a. Pain at the incision site b. Decreased appetite c. Slight redness and itching at the incision site d. Clear drainage from the incision site

d The finding of clear fluid on the dressing after a laminectomy strongly suggests a cerebrospinal fluid leak, which constitutes an emergency. The client has in increased risk of meningitis with a spinal fluid leak. Pain, redness, and itching at the site are normal.

A client with open burn wounds begins to have diarrhea. The client is found to have a below-normal temperature, with a white blood cell count of 4000/mm3. Which action by the nurse is most appropriate? a. Continue to monitor the client. b. Increase the temperature in the room. c. Increase the rate of intravenous fluids. d. Prepare to do a workup for sepsis.

d These findings are associated with systemic Gram-negative infection and sepsis. To verify that sepsis is occurring, cultures of the wound and blood must be taken to determine the appropriate antibiotic to be started. Continuing just to monitor the situation can lead to septic shock. Increasing the temperature in the room may make the client more comfortable, but the priority is finding out whether the client has sepsis and treating it before it becomes a shock situation.

A nurse is at the scene of a lightning strike during a thunderstorm. Which is the priority action of the nurse? a. Make sure that victims are not electrically charged. b. Assess victims for second- and third-degree burns. c. Start emergency resuscitation on anyone not breathing. d. Move victims and first aid responders to a sheltered area.

d Victims of a lightning strike are not electrically charged afterward. Cardiopulmonary resuscitation (CPR) should be started once victims and first aid responders are in a sheltered area, because the thunderstorm presents a continued threat of lightning strikes.

The nurse is planning care for a client who is newly wheelchair bound owing to a spinal cord injury. What priority intervention should the nurse include in the plan of care to assist the client in transferring from the bed to the wheelchair? a. A diet high in protein and low in calories b. An occupational therapy consult c. Bowel and bladder retraining d. Upper arm strengthening exercises

d With impaired mobility and use of a wheelchair, the client tends to gain weight. During rehabilitation, the client should be on a high-protein diet but not calorie restriction. The increased weight requires greater upper body strength for movement. The nurse should encourage the client to perform exercises that strengthen the upper arms. The nurse should consult physical therapy to assist with these exercises