What should the nurse do first when a hospitalized client tells the nurse about feeling a strong shock when turning on an electric dryer?
- Assess apical pulse
- Disconnect the hairdryer from electrical outlet
Disconnect the hairdryer from electrical outlet
The client was ordered to have cimetidine IV. The client’s family asks why this drug is being given, what is the nurse’s best response?
- To stimulate intestinal movement and prevent abdominal bloating
- To decrease hydrochloric acid production in the stomach and prevent ulcers.
To decrease hydrochloric acid production in the stomach and prevent ulcers.
The nurse is caring for a toddler with 2nd degree burn and 3rd degree burns over 20% of the body 8 hours post injury. The most critical nursing diagnosis for this patient is?
- Risk for infection
- Deficient fluid volume
Deficient fluid volume
(Main problem before the risk diagnosis)
A nurse is assessing a 16 yr old adolescent in an emergency department who has been admitted because of burns over 25% of the client’s body. Upon initial examination, the nurse makes several observations. Which observation should be most concerning to the nurse?
- Areas on upper extremities are mottled
- Areas on lower extremities are waxy
- Areas on upper extremities are moist and red
Areas on lower extremities are waxy
A client is brought to the emergency department after a severe burn caused by a fire at home. The burns are extensive, covering greater than 25% of the total body surface area. When the nurse reviews the laboratory results drawn on the client which value should the nurse most likely to expect to note?
- Hct 65%
- Albumin 4.5g/dL
- Na 145 mEq/L
- WBC 7000 cells/mm3
Hct 65%
Prioritize which client should you attend first
1: Unresponsive with penetrating head injury
2: A client with sucking chest wound
3: A client with third-degree burns over 65% of the body surface area
4: A client with a maxilla fracture and a facial wounds without airway compromise.
A client with third-degree burns over 65% of the body surface area
Unresponsive
Partially unresponsive
Without airway compromise
Which medication should a nurse apply topically in a client with second and third degree burns to treat bacterial and yeast infections?
- Gold sodium thiomalate
- Bismuth subsalicylate
- Silver sulfadiazine
- Arsenic trioxide
Silver sulfadiazine
Identify the extent of the patient’s injury:
- Upper half arm
- Anterior torso
- Lower half of both arms
anterior of the head - Upper half of the posteriro torso
31.5%
What is the flow rate during the First 8hrs ml/Hr based on the total you calculated?
- front and back of the right and left leg
- front of the right arm
- Anterior trunk
- Patient weight: 63 kg
921 ml/hr
Health counseling of patient with hiatal hernia. Which info should you include?
- Restrict high carbohydrate foods
- Eat 3 regualr meals a day
- Increase fiber intake
- Increase fat intake
Increase fiber intake
After Billroth II surgery, a client experiences weakness, diaphoresis, anxiety, and palpitations 2 hours after a high carbohydrate meal. The nurse would interpret that these symptoms indicate the development of?
- Duodenal reflux
- Gerd
- Post prandial hypoglycemia
Post prandial hypoglycemia
The serum ammonia level of a patient with cirrhosis is elevated. As a priority, a nurse should plan to:
- Observe for increasing confusion
- Measure the urine specific gravity
- Restrict the client’s oral fluid intake
- monitoring of temperature q4
Observe for increasing confusion
Caring a client with Sengstaken Blakemore Tube, what should the nurse anticipate to have at the client’s bedside?
Scissor
A nurse suspects acute pancreatitis when a client reports?
A sudden onset of pain in the upper left abdominal quadrant that radiates to the back
Anatomy
A client was recovering from acute pancreatitis ask when he can able to eat again?
When the pain is controlled and serum lipase level has decreased
Pancreatitis pain control includes the…
Pancreatic enzymes and H2 Blocker medications
A nurse is assessing a client diagnosed with acute diverticulitis. Which finding should make the nurse suspect that the client has an intestinal perforation
Absent bowel sounds
