A nurse reviews the laboratory results for a client who was burned 24 hours ago. Which laboratory result should the nurse report to the health care provider immediately?
a. Arterial pH: 7.32
b. Hematocrit: 52%
c. Serum potassium: 6.5 mEq/L
d. Serum sodium: 131 mEq/L
ANS: C
The serum potassium level is changed to the degree that serious life-threatening responses could result. With such a rapid rise in potassium level, the client is at high risk for experiencing severe cardiac dysrhythmias and death. All the other findings are abnormal but do not show the same degree of severity; they would be expected in the emergent phase after a burn injury.
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Nursing responsibilities when applying and monitoring restraints include: Standard Text: Select all that apply
1. Assess the restraint every 2–4 hours. 2. Apply a restraint such that it can be released quickly in case of an emergency. 3. Provide emotional support verbally and through touch. 4. Ensure that limb restraints are applied securely but not too tightly. 5. Record interventions at the end of the shift.
A client tells the nurse that on discharge following the client's transurethral resection, his wife is going to drive him to his daughter's house 3 hours away to recuperate. The nurse's most appro-priate response would be
a. "During the drive, be sure to stop every hour to void." b. "I'm glad you have someone to help you after your operation." c. "Try to limit fluid intake before the drive to avoid problems." d. "You need to avoid prolonged sitting for 2 weeks; can you plan something else?"
A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient's assessment indicates a manifestation associated with this disorder?
1. The patient described severe nightmares related to the event. 2. The patient denied anger or shock. 3. The patient denied the need for drug or alcohol counseling. 4. The patient stated that her family is very supportive.
A school nurse has recently noticed a dramatic increase in the number of students suffering from asthma attacks while in the school building
The nurse knows that the school, though cleaned frequently, is in a very old building. How should the nurse proceed? A. Review student health records and obtain statistics on the number of students being diagnosed with asthma and having asthma attacks while in school over the last ten years. B. Instruct the custodial staff to replace the ventilation and furnace systems. C. Obtain a copy of the EPA Indoor Air Quality Tools for School Action Kit and work with the principal to implement the goals outlined in the guide. D. Send letters home to the parents of affected kids requesting follow-up with their pediatricians.