The nurse is providing put up-technique care to a patron who had a cardiac catheterization. The
client begins to manifest symptoms & symptoms related to embolization. Which movement have
to the nurse take?
A. Notify the primary healthcare issuer straight away
b. Apply a warm, moist compress to the incision web page
c. Increase the intravenous fluid price by using 20 mL/hr
d. Monitor vital symptoms more regularly
ANS = D
A customer reviews left-sided chest pain after gambling racquetball. The customer is
hospitalized & recognized with left pneumothorax. When assessing the customer's left chest
area, the nurse expects to become aware of which locating?
A. Dull sound on percussion
b. Vocal fremitus on palpation
c. Rales with rhonchi on auscultation
d. Absence of breath sounds on auscultation
ANS = C
A customer is admitted to the clinic with partial- & full-thickness burns of the chest & face
sustained while seeking to extinguish a brush hearth. Which is the nurse's priority concern?
A. Loss of pores and skin integrity caused by the burns
b. Potential infection due to the burn damage
,c. Inadequate gas alternate due to smoke inhalation
d. Decreased fluid quantity due to the depth of the burns
ANS = B
During the first 48 hours after a consumer has sustained a thermal harm, which situations need
to the nurse determine for?
A. Hypokalemia & hyponatremia
b. Hyperkalemia & hyponatremia
c. Hypokalemia & hypernatremia
d. Hyperkalemia & hypernatremia
ANS = C
A patron who had considerable pelvic surgical operation 24 hours in the past turns into cyanotic,
is gasping for breath, & reviews proper-sided chest pain. What must the nurse do first?
A. Obtain crucial signs and symptoms
b. Initiate a cardiac arrest code
c. Administer oxygen the use of a face mask
d. Encourage using an incentive spirometer
ANS = C
A nurse is caring for a customer with severe burns. The nurse determines that this consumer is
at danger for hypovolemic shock. Which physiologic locating helps the nurse's conclusion?
A. Decreased fee of glomerular filtration
b. Excessive blood loss via the burned tissues
c. Plasma proteins transferring out of the intravascular compartment
,d. Sodium retention going on because of the aldosterone mechanism
ANS = A
The nurse is worrying for a patron with burns & reviews the client's laboratory results: BUN 30
mg/dL; Cr 2.4 mg/dL; serum potassium 6.3 mEq/L; pH, 7.1; PO₂ ninety mm Hg; & Hgb 7.4 g/dL.
Which circumstance does the nurse suspect the client has primarily based upon those findings?
A. Azotemia
b. Hypokalemia
c. Metabolic alkalosis
d. Respiratory alkalosis
ANS = D
A nurse is being concerned for a purchaser who experienced critical burns in a fireplace. Which
courting among a consumer's burned body surface vicinity & fluid loss need to the nurse keep in
mind whilst comparing fluid loss in a patron with burns?
A. Equal
b. Unrelated
c. Inversely associated
d. Directly proportional
ANS = C
A burn customer is receiving the open technique for wound remedy. Which statistics will the
nurse explain to the patron?
A. Bathing will no longer be authorized
b. Dressings might be changed each day
c. Personal shielding device will be worn by using body of workers
, d. Room temperature may be saved beneath 72° F (22.2° C)
ANS = A
A customer provides to the emergency department with weak spot & dizziness. The BP is 90/60
mm Hg, pulse is 92 & vulnerable, & body weight reflects a three-pound loss in two days. The
climate has been hot. Which circumstance have to the nurse conclude is the priority for this
purchaser?
A. Deficient fluid extent
b. Impaired skin integrity
c. Inadequate nutritional intake
d. Decreased participation in sports
ANS = B
A customer is admitted with extreme burns. The nurse is caring for the patron 36 hours after the
consumer's admission & identifies the patron's potassium stage of 6.0 mEq/L. Which drink will
the nurse recommend be covered inside the customer's weight loss plan?
A. Milk
b. Tea
c. Orange juice
d. Tomato juice
ANS = A
A lady involves the workplace of her healthcare company reporting shortness of breath &
epigastric distress that isn't always relieved by using antacids. To which question could a girl
experiencing a myocardial infarction respond in a different way than a person?
A. "Do you have got chest pain?"
b. "Are you feeling anxious?"
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