The nurse is caring for a patient admitted to the burn unit with burns to 45% of the body. After 3 days, the nurse notes that the patient's temperature is newly elevated at 100.2°F (37.9°C), and the patient exhibits new-onset agitation and confusion
What should the nurse do first?
a. Increase oral fluids to 3000 mL/day.
b. Notify the registered nurse (RN) or primary care provider.
c. Monitor the patient for further changes in mental status.
d. Administer a prn dose of acetaminophen (Tylenol) for the fever.
ANS: B
The nurse should continually assess for and report signs and symptoms of sepsis: temperature elevation, change in sensorium, changes in vital signs and bowel sounds, decreased output, and positive blood/wound cultures. A rise in temperature should be reported. A. C. D. Further monitoring, Tylenol, and fluids may also be appropriate but only after the HCP determines the cause of the change and provides recommendations.
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Which suggestion, offered by the nurse, is helpful in producing the sputum sample? A) Tickle the back of the throat to produce the gag reflex. B) Drink 8 oz of water to thin the secretions for expectoration. C) Use the secretions present in the oral cavity. D) Take deep breaths and cough forcefully.
A nurse suspects that a preterm newborn is having problems with thermal regulation. Which of the following would support the nurse's suspicion? (Select all that apply.)
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The nurse is assessing a 68-year-old female patient who states, "I am having episodes of urinary incontinence.". The nurse should recognize that this statement indicates which situation?
1. An abnormal finding requiring further testing 2. The presence of a urinary infection 3. A normal outcome of the aging process 4. The result of having several children
The nurse is assessing a woman with abruption placentae who has just given birth. The nurse would be alert for which of the following?
A) Severe uterine pain B) Board-like abdomen C) Appearance of petechiae D) Inversion of the uterus