During the immediate postburn period, the nurse assesses the client for injuries other than burns. Which of the following assessments indicates a potential problem?
1. Coughing
2. Urine output of 30 ml/hour
3. Presence of eschar
4. Presence of edema
Coughing
Rationale: Coughing could indicate either an inhalation injury or a cold. Urine output of
30 ml/hour is a normal finding. The presence of eschar and edema are normal manifestations of burn injuries.
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A nurse suspects that a postpartum client is experiencing postpartum psychosis. Which of the following would most likely lead the nurse to suspect this condition?
A) Delirium B) Feelings of anxiety C) Sadness D) Insomnia
The client is having a tonic-clonic seizure. Which should the nurse implement during the client's seizure to maintain the airway?
1. Apply chin-lift position. 2. Insert a curved oral airway. 3. Sit client in upright position. 4. Turn client's head to the side.
The nurse has to complete a cardiac assessment on a client. Which level of human proxemics would be appropriate for the nurse in completing this assessment on the client?
A) Intimate B) Personal C) Social D) Public
The greater affinity that fetal hemoglobin has for oxygen allows for
A. Easier release of oxygen to the tissues B. Greater binding of oxygen C. Stimulation of erythropoietin release