A patient is severely burned over the neck, chest, both arms, and both legs. How should the nurse facilitate fluid resuscitation of this patient?
1. Defer placement of an IV line until the physician can place a central line.
2. Carefully assess the arms and legs for nonburned venous access.
3. Start a small-bore IV catheter in a nonburned area of the hand.
4. Start large-bore IV catheters through burned areas.
4
Rationale 1: The nurse should not defer IV line placement.
Rationale 2: The nurse should not take time for a careful assessment.
Rationale 3: A small-bore catheter is not sufficient for venous access.
Rationale 4: Though not optimal, the nurse should start large-bore IV catheters through burned flesh to begin fluid therapy as soon as possible.
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A patient receiving a 17–alpha-alkylated androgen telephones to report a recent yellowing discoloration of his skin and eyes. The nurse should instruct him to:
a. continue the drug, as development of slight jaundice is expected. b. discontinue the drug and come to the office for blood tests. c. proceed to the radiology department for a CT scan of his abdomen. d. start a 3-day course of antihistamines, as this is characteristic of an allergic reaction.
Often nurses and other health care providers fail to recognize violations of patient autonomy. Which of the following is an example? Select all that apply
a. Nurses failure to recognize that individual's thought processes are the same. b. Attentiveness to patient autonomy is sometimes neglected as the work of nursing becomes the major focus. c. Nurses may falsely assume that patients have the same values and goals as themselves. d. Assuming patient have more knowledge than is reasonable for them to have.
The nurse is helping a client prepare menus to reflect dietary changes the physician has ordered due to the recent diagnosis of CHD. The nurse recognizes whole grains are essential in this diet change
Which of the following components of whole grains have been implicated in providing benefits for clients with CHD? Select all that apply. A) Vitamin K D) Fiber B) B vitamins E) Phytochemicals C) Vitamin C
After checking a patient's blood pressure, he asks the nurse what changes he should expect in himself as he grows older. Which response by the nurse would be most appropriate?
A) "You don't have anything to worry about; you will basically stay the same." B) "Your personality will stay the same, but your intelligence level will lessen somewhat." C) "Usually, you can anticipate that you will begin to react to things more slowly." D) "You will become increasingly childlike, and your personality will change."