The nurse is caring for a client who was involved in a motor vehicle accident and experienced blunt force trauma to the chest because she did not have a seat belt on and her chest impacted with the steering wheel
The nurse monitors the client for: 1. Hypovolemic shock.
2. Cardiogenic shock.
3. Septic shock.
4. Neurogenic shock.
2
Rationale: Cardiogenic shock can result from trauma to the chest if there is injury to the pericardium, because the inflammation and edema could reduce the heart's ability to contract, thereby reducing cardiac output.
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The nurse is caring for an older client with asthma that has a respiratory rate of 28 breaths per minute and audible wheezes on inspiration. Which nursing diagnosis is most important for this client?
1. Activity intolerance 2. Altered peripheral tissue perfusion 3. Ineffective airway clearance 4. Ineffective breathing pattern
A client who weighs 90 kg and had a 50% burn injury at 10 AM arrives at the hospital at noon. Using the Parkland formula, calculate the rate that the nurse should use to deliver fluid when the IV is started at noon
What will be an ideal response?
If a patient is more confused than yesterday, the best way to document this would be
a. "Patient is confused more today than yesterday." b. "Patient is sleeping a lot." c. "Patient is not able to state where he is, who he is, what time it is, what place he is in." d. "Patient is hard to talk to."
The nurse notices the UAP about to enter Raymond's room to deliver a meal tray without wearing any protective apparel. What information should the nurse provide to the UAP?
A. A mask is required for healthcare workers entering the room of someone suspected of having active TB B. Wearing a mask, gown, and gloves is required for healthcare workers entering Raymond's room for any reason C. The UAP will only be in the room for a brief moment to deliver the tray so no intervention is needed by the nurse D. Non-sterile gloves are necessary to deliver the meal and prevent the spread of TB