Which of the following factors increase the burn patient's risk for venous thromboembolism? (Select all that apply.)
a. Burn injury less than 10%
b. Bedrest
c. Burns to lower extremities
d. Electrical burn injury
e. Delayed fluid resuscitation
B, C, E
Venous thromboembolism (VTE) is a significant risk for patients who have thermal injury, venous stasis associated with immobility/bedrest, hypercoagulability seen with burn injuries greater than 10% TBSA, and hypovolemia associated with delayed fluid resuscitation. Burns to lower extremities will limit mobility and use of sequential compression devices, increasing the potential risk for VTE. Electrical burn injury may pose a risk for VTE; however, VTE is more closely associated with thermal injuries greater than 10% TBSA.
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What is the nursing action that has the highest priority for a client experiencing hypertonic contractions during oxytocin stimulation of labor?
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The nurse is conducting a home care assessment for a patient who was recently discharged from the hospital after being treated for pneumonia. Which question is asked to assess the patient's risk for impaired skin integrity?
1) "Do you have clean clothes to wear?" 2) "Who is responsible for doing the laundry?" 3) "Do your clothes properly fit?" 4) "Do you require assistance when dressing?"
The nurse caring for a 78-year-old male client recovering from hip replacement surgery is as-sessing for signs of improvement of the client's activity tolerance. The nurse determined a base-line for ongoing assessments by:
1. Determining how much time it takes the client to recover from an activity 2. Assessing how much the client can do at one time 3. Determining the level of pain experienced by the client during the activity 4. Asking the client how much the client feels like doing