The client, who is 2 weeks postburn with a 40% deep partial-thickness injury, still has open wounds. On taking the morning vital signs, the client is found to have a below-normal tem-perature, is hypotensive, and has diarrhea
What is the nurse's best action? A. Nothing, because the findings are normal for clients during the acute phase of re-covery.
B. Increase the temperature in the room and increase the IV infusion rate.
C. Assess the client's airway and oxygen saturation.
D. Notify the burn emergency team.
D
These findings are associated with systemic gram-negative infection and sepsis. This is a medical emergency and requires prompt attention.
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To enhance gas exchange, the nurse would position a patient who had a left pneumonectomy this morning:
1. on the right side. 2. on the left side. 3. in a semi-Fowler's position. 4. flat, with a small pillow.
About which of the following should the nurse instruct the parents of a preschool age child regarding eye safety?
1. Keeping sharp objects out of reach of young children 2. Supervising when lighting fireworks 3. Wearing eye goggles when playing outdoors at all times 4. Keeping household products within easy reach
Constrict means to:
a. Expand or open wider b. Narrow c. Reduce blood flow d. Increase blood flow
Prior to conducting an eye assessment, which statement by the nurse is appropriate to prepare the client for the examination process?
A. "You can choose which eye to cover during your assessment." B. "Apply pressure to the eye while it is covered during the examination." C. "You will need to stand 10 feet from the chart for an accurate assessment." D. "Are you able to read English words?"