During the first 24 hours after a burn, fluid replacement is the treatment priority. Which assessment should alert the nurse that the fluid protocol is ineffective?
a. Rectal temperature of 101° F
b. Urine output of 20 mL/hr
c. Crackles in the lower left lobe
d. Significant edema in the burn area
B
Decreased urinary output indicates that poor perfusion to the kidney still remains. Temperature elevation and edema are to be expected. Crackles in a patient who is dormant are not causes for alarm.
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The nurse is applying a dry gauze dressing to the client's large abrasion. The client asks the nurse why he needs a dressing on it. Appropriate responses include:(Select all that apply) Standard Text: Select all that apply
1. The dressing will protect the wound from being contaminated by germs 2. Wounds heal better when they are kept warm, and the dressing will provide insulation 3. The wound may drain as it heals, and the dressing will absorb the drainage 4. The wound needs to be kept moist 5. This will prevent the wound from hemorrhaging
Twenty minutes after birth, a baby begins to move its head from side to side, making eye contact with the mother, and pushes its tongue out several times. The nurse interprets this as:
A) a good time to put the baby to breastfeed B) the period of decreased responsiveness preceding sleep C) the need to be alert for gagging, vomiting, and urinating D) evidence that the newborn is becoming chilled
A nurse is providing care for a client with a diagnosis of Crohn disease. The nurse recognizes the fact that the disease involves the inflammation and irritation of the intestinal lining
Which of the following types of tissue is most likely involved in the client's pathology? A) Simple columnar epithelium B) Glandular epithelium C) Simple cuboidal epithelium D) Stratified epithelium
An appropriate nursing intervention for a patient with non-Hodgkin's lymphoma whose platelet count drops to 18,000/µL during chemotherapy is to
a. check all stools for occult blood. b. encourage fluids to 3000 mL/day. c. provide oral hygiene every 2 hours. d. check the temperature every 4 hours.