The nurse is caring for an older patient with a burn injury. Because preexisting health conditions influence how the older patient responds to the resuscitative treatment, the priority when caring for this patient would be:
1. Calculating nutritional needs
2. Coordinating physical therapy
3. Managing pain
4. Fluid resuscitation
4
Rationale 1: This is not the immediate priority.
Rationale 2: This is not the immediate priority.
Rationale 3: This is not the immediate priority.
Rationale 4: Based on the strategy of ABCs (airway, breathing, and circulation), fluid resuscitation is the greatest priority. The patient with heart problems must be closely monitored during fluid resuscitation and a balance must be maintained between providing adequate resuscitation to the tissues and further stressing the heart.
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Osmotic diuretic therapy to prevent increasing intracranial pressure (ICP) has not been successful for a client. Which surgical procedure should the nurse anticipate being prescribed for this client?
1. Lumbar surgery 2. Bone flap surgery 3. Carotid artery surgery 4. Surgery to place a drain to the brain through the ear
Your client is about to have a skin test for an allergic disorder. What critical instruction should the nurse give this client?
A) Avoid red meat for 48 to 72 hours before the test. B) Avoid strenuous physical activity for 24 hours before the test. C) Avoid antihistamines and cold preparations for 48 to 72 hours before the test. D) Avoid sunlight for 48 to 72 hours before the test.
A 70-year-old patient is sunburned over much of the body. What self-care technique is MOST important to emphasize to an older adult to deal with the effects of sunburn?
1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth
Ms. J is a 15-year-old girl who is 2 months pregnant. If Ms. J later confides to the nurse that she craves the taste of laundry starch, the nurse would document this incidence of:
1. Eclampsia 2. Gestational diabetes 3. Heartburn 4. Pica