When monitoring the vital signs of a patient who has sustained a major burn injury, the nurse assesses a heart rate of 112. What should the nurse determine about this finding?
A. This heart rate is normal for the patient's post-burn injury condition.
B. The patient is demonstrating manifestations consistent with the onset of an infection.
C. The patient is demonstrating manifestations consistent with renal failure.
D. The patient is demonstrating manifestations consistent with an electrolyte imbalance.
Answer: A
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Which nursing assessment finding is most indicative of a hemorrhagic stroke?
A) Client history of atrial fibrillation B) Sudden onset of breathing alterations C) Symptoms evolving over 24 to 48 hours D) Client history of hyperlipidemia
The process of delegation may be undermined in the health care setting as one member of the team moves work in a downward direction. What are some of the reasons for delegatees to resist responsibility (select all that apply)?
a. Lack of ability to direct b. Fear of criticism for mistakes c. Overwhelming workload d. Lack of confidence e. Lack of resources
The nurse is caring for a client with an AV fistula. Upon assessment the nurse notes that the extremity with the fistula is pale and cool. The nurse would initially:
1. Auscultate the fistula. 2. Notify the health care provider. 3. Check vital signs. 4. Document the finding.
The nurse measures the blood pressure in the leg due to the fact that the client has bilateral casts on the upper extremities. The nurse palpates the pulse before the measurement at the:
1. Popliteal fossa behind the knee 2. Inner side of the ankle below the medial malleolus 3. Top of the foot between the extension tendons of the great toe 4. Inguinal ligament midway between the symphysis pubis and the anterior superior iliac spine