Which of the following nursing observations of the client who is severely burn injured would indicate a less-than-desirable client status and should be immediately reported to the doctor?
a. a change in the client's level of consciousness from confused to alert
b. hourly urine output below 30 mL
c. pulse oximetry reading that remains above 90%
d. productive cough
B
Medical management of clients who sustain severe burn injury is initially focused on immediate lifesaving measures such as maintaining an open airway, replacing fluid and electrolytes, providing oxygenation, controlling pain, monitoring kidney function (hourly urine output of at least 30 mL), and minimizing loss of body temperature and risk of infection.
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A nurse is caring for a refugee patient who wants the community shaman to perform a healing ritual at the bedside. What action by the nurse is best?
a. Work with the patient to allow the shaman to perform the ritual. b. Investigate whether the ritual will harm the patient. c. Check to see if the ritual breaks laws or policies. d. Offer to call the hospital chaplain instead.
A couple is at the clinic for preconceptual counseling. Both parents are 40 years old
The nurse knows that the education session has been successful when the wife makes which statement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. "We are at low risk for having a baby with Down syndrome." 2. "Our children are more likely to have genetic defects." 3. "Children born to parents this age have sex-linked disorders." 4. "The tests for genetic defects can be done early in pregnancy." 5. "It will be almost impossible for us to conceive a child."
The community health nurse addresses an outbreak of viral spinal meningitis in the community. Referring to Leavell and Clark's natural history of disease model, which example of tertiary prevention might the nurse consider in this situation?
A) Initiate vaccinations for all people who have not yet been infected. B) Familiarize yourself with the signs and symptoms of the disease so that you can provide early diagnosis and treatment of it. C) Encourage any who think they might have symptoms of the disease to come to the community health clinic to be assessed as soon as possible, to prevent associated disabilities. D) Refer clients who have experienced neurological deficits because of the disease to a neurologist to begin rehabilitation.
A client presents with shock in the hospital, and has a history of a recent infection. What does the nurse suspect that this client is experiencing?
1. Septic shock 2. Hypovolemic shock 3. Cardiogenic shock 4. Neurogenic shock