The nurses calculating fluid resuscitation for young adult male who was burned in a bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the client has burn over 30% of his body, mainly over his arms and chest. Using the Parkland formula for fluid resuscitation, the client...
the nurses calculating fluid resuscitation for young adult male who was burned in a bloody accident at 1200 and is seen in the er at 1400
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The nurses calculating fluid resuscitation for young adult male who was burned in a
bloody accident at 1200 and is seen in the ER at 1400. The HCP determines that the
client has burn over 30% of his body, mainly over his arms and chest. Using the
Parkland formula for fluid resuscitation, the client is to receive 7000 mL of fluid in 24
hours. Which goal should the nurse establish for this client plan of care? - ANSWER By
2000, the client will have received 3500 mL of fluid
When caring for a client on a vent, which finding provides the greatest indication that the
client has an open airway? - ANSWER Bilateral breath sounds can be auscultated
The nurse performs a prescribed a neurological check at the beginning of the shift on a
client who was admitted with a subarachnoid brain attack (Stroke). The client's GCS is
9. What information is most important for the nurse to determine? - ANSWER The
client's previous GCS score
An adult female with a history of type 1 diabetes has been vomiting for the past 48
hours and is admitted to the ICU with DKA. Which assessment finding warrants
immediate intervention by the nurse? - ANSWER Excessive thirst
A client admitted to the ICU after a colon resection with the formation of the loop
colostomy. The nurse determines that the clients abdominal dressing is clean and dry.
Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine output of 10 mL/hr.
What interventions should the nurse implement? - ANSWER Give a 500 mL IV fluid
bolus challenge
A client is admitted with syncopal episodes related to a third degree heart block. After
the placement of a transcutaneous pacemaker, the nurse observes several episodes
the pacemaker failure to sense. What action should the nurse take? - ANSWER
Increase the sensitivity
A client is receiving CPR. After systole is confirmed in two leads and sending the
transcutaneous pacemaker, which IV medication should be administered? - ANSWER
Epinephrine (adrenaline)
A client has a chest tube connected to a closed water seal drainage system with
suction. What equipment should the nurse always have available at the clients bedside?
- ANSWER Occlusive dressing
, Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia.
The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should
program the infusion time to deliver how many mL/hr? - ANSWER 30
The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6 mL/hr.
How many mcg/min of nitroglycerin is infusing? - ANSWER 20
A client arrives in the ER complaining of pain. What description of pain should prompt
the nurse to suspect it originated in the myocardium? - ANSWER Produces chest
heaviness with left arm pain
Four days ago a chest tube was inserted into the second intercostal space of a client
who has a pneumothorax. Today the nurse notes that there is no fluctuation in the
water-seal chamber of the Pleuravac. Which intervention would be most appropriate for
the nurse to implement? - ANSWER Assess the clients breath sounds of the affected
lung
In developing a care plan for a client that has a chest tube due to a hemothorax, the
nurse should recognize which intervention is essential? - ANSWER Encourage the
client to breathe deeply and cough at frequent intervals
A postoperative client is admitted the ICU with an inflated pressure infuser containing
solution of heparin 2 units/mL attached to an intraarterial cannula. Which finding
indicated that the heparin infusion has achieved its therapeutic use? - ANSWER Intra-
arterial cannula remain patent
The nurse suspects that a client with a central venous catheter in the left subclavian
vein is experiencing an embolism. What signs and symptoms are most indicative of this
condition? - ANSWER Anxiety, confusion, lightheadedness, and loss consciousness
A female client has been in systole for 20 minutes. She is intubated, and epinephrine
(adrenaline) 1 mg and atropine sulfate 1 mg IV were administered, with no change in
rhythm. What intervention should the nurse implement? - ANSWER Bring members of
the family to a private area to discuss the desire to continue life saving efforts
The nurse is evaluating a clients central venous pressure reading that are trending
upwards. What nursing diagnosis is supported but the pathophysiological mechanism
most likely causing this increase? - ANSWER Impaired cardiac output
The high pressure alarm on a mechanical vent is alarming. What intervention should the
nurse implement immediately? - ANSWER Auscultate bilaterally for breath sounds and
confirm endotracheal suctioning
A client with a history of vasovagal attacks resulting in brady-dysrhythmias. Which
instruction is the most important in the teaching plan? - ANSWER Use stool softeners
regularly
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