During the acute phase of burn injury, the patient has the risk of developing complications. The nurse would assess for the presence of:
1. Hypovolemic shock
2. Septic shock
3. Wound scarring
4. Urinary tract infection
2
Rationale 1: This would occur during the resuscitative phase due to large amount of fluid loss.
Rationale 2: During the acute phase, fluid resuscitation is complete and the patient is at risk for sepsis and septic shock.
Rationale 3: This would occur during the rehabilitative phase as healing is occurring.
Rationale 4: Even though the presence of an indwelling urinary catheter can contribute to a urinary tract infection, it is not unique to the burn patient.
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Sinus bradycardia (rate 56 beats per minute) is identified in a sleeping patient on telemetry. Which is the priority nursing action?
1. Assess the patient's tolerance of the rhythm. 2. Call the physician and report this dysrhythmia. 3. Check the medication administration record and see if there is a PRN medication that will improve this rhythm. 4. Call for an immediate 12-lead electrocardiogram (ECG).
Which statement made by the client taking an immunosuppressive agent to manage rheumatoid arthritis would require further teaching by the nurse?
1. "I should drink a lot of fluids like grapefruit juice.". 2. "I know I'll have to cope with having my blood drawn regularly.". 3. "This medication may cause damage to my kidneys.". 4. "If I experience any joint pain, I can take ibuprofen as needed every 4 hours.".
The nurse is asked to prepare for the hospital admission of a child with sickle cell disease (SCD) who is being admitted for the treatment of vaso-occlusive pain crisis
The nurse prepares for the admission, anticipating that which of the following will be prescribed for the child? 1. NPO status 2. Intravenous (IV) fluids 3. Meperidine (Demerol) for pain 4. Intubation for the administration of oxygen
When the post-tonsillectomy patient is fully awake, the nurse may offer:
a. Small sips of orange juice b. Cold carbonated drinks c. A strawberry popsicle d. Cool sweetened tea