An adult suffered burns to face and

An adult suffered burns to face and chest resulting from a grease fire. On admission, the client was intubated and a 2 liter bolus of normal saline was administered IV. Currently the normal saline is infusing at 250 mL/hour. The client’s heart rate is 120 beats/minute, blood pressure is 90/50 mmHg, respirations are 12 breaths/minute over the ventilated 12 breaths for a total of 24 breaths/minute, and the central venous pressure (CVP) is 4 mm H,O. Which intervention should the nurse implement? A Bring a tracheotomy tray to the bedside. B Infuse an additional bolus of normal saline C. Increase the oxygen delivered by the ventilator. D.Lower head of the bed to a recumbent position. 2 When assessing an older male cient, the nurse finds that he is experiencing orthopnea and has an oxygen saturation reading of 93%. Auscultation of the lungs reveals crackles and bilateral pedal edema are present In which order should the nurse implement these actions? (Arrange in the order from first on top to last on the bottom.) Provide oxygen per nasal cannula. Administer a prescribed dose of furosemide. Raise the head of the bed to Fowler’s position. Monitor urinary output. 3. The nurse is caring for a client who reports sudden right-sided numbness and weakness of the arm and leg. The nurse also observes a distinct right-sided facial droop. After reporting the findings to the healthcare provider, the nurse receives several prescriptions for the client, including a STAT computerized tomography scan of the head. Which action should the nurse take first? A. Raise the head of the bed to 30 degrees keeping head and neck in neutral alignment. B. Administer aspirin to prevent further clot formation and platelet clumping C. Begin continuous observation for transient episodes of neurologic dysfunction. D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy 4 A client, who is a veteran, comes to the emergency department appearing tense, anxious, and having difficulty concentrating on the questions the nurse is asking during the health history. Which client statement is most important for the nurse to document? A. *I can’t forgive myself for leaving my buddy behind.” B. *I am having a lot of trouble sleeping most nights.” C. “I worry I’ll get fired because I call in sick so often.” D. “I can’t seem to shake out of these helpless feelings” 5 nurse assumes care of a postoperative adult client with type 2 diabetes mellitus and leams that the client has a current blood glucose level of 750 mg/dL. (42 mmolL). When assessing the client, what is the priority? A. Observe wound drainage characteristics. B. Assess for signs of fluid volume deficit. C. Determine when the client last ate. D. Measure the level of acute pain. 6 The nurse requests a meal tray for a client who follows Mormon beliefs and who is on a clear liquid diet following abdominal surgery. Which menu items should the nurse request for this client? (Select all that apply) A. Black coffee B. Apple juice. C. Orange juice D. Hot chocolate E. Chicken broth SCIENCE HEALTH SCIENCE NURSING NURSING 213

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