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,A client in the intensive care unit (ICU) c. Multiple organ dysfunction syndrome (MODS)
was recovering from moderate burns and
smoke inhalation. His condition was
improving, and plans were made to
transfer him to
a step-down unit. On the morning of the
transfer, the client began to experience
elevated temperatures and shortness of
breath. Urine output decreased to 10ml/hr.
Labs
were drawn and indicated elevated white
blood cells (WBC), glomerular filtration rate
(GFR) creatinine and liver enzymes. This
client is experiencing which medical
complication?
a. Disseminated Intravascular coagulation
(DIC)
b. Acute respiratory failure (ARF)
c. Multiple organ dysfunction syndrome
(MODS)
d. Acute kidney injury (AKI)
A nurse is educating a new nurse on the d. A client with a tension pneumothorax and cardiovascular compression
different types of shock. The new nurse
asked
to identify which client is not experiencing
distributive shock?
a. A client with septic-induced
hypotensionrefractory to adequate fluid
resuscitation
b. A client with extensive spinal
cord injuryat T4 and a heart rate of 40
beats per minute
c. A client with extreme type of
allergicreaction to penicillin and stridor
d. A client with a tension
pneumothoraxand cardiovascular
compression
A nurse is managing several IV b. Norepinephrine
medications to maintain the blood pressure
of a client
in hypovolemic shock. Which medication
places the client at risk for a hypertensive
reaction requiring the nurse to assess the
blood pressure at least every 15 minutes?
a. adenosine
b. Norepinephrine
c. sodium nitroprusside
d. amiodarone
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, A nurse is caring for a client who is in c. Normal Saline solution (Blood can only be administered with NS)
hypovolemic shock related to hemorrhage.
The nurse
prepares intravenous (IV) tubing to infuse
with which IV solution in preparation for a
blood transfusion?
a. 3% Sodium chloride solution
b. Total parenteral nutrition
c. Normal Saline solution (Blood
can onlybe administered with NS)
d. Lactated Ringer's solution
A nurse is caring for a client who suffered b. Arterial blood gas (ABG) results show PaO2 50 mmHg
a third-degree burn to his hands after a
house
fire. He presented with an airway injury
secondary to smoke inhalation and has
been
intubated. The client is currently on the
incubator with 100% FiO2. Based on this
information, which of the following would
be a sign or symptom of acute respiratory
distress syndrome (ARDS)?
a. Respiratory rate 14 breaths/minute
b. Arterial blood gas (ABG) results show
PaO2 50 mmHg
c. Fatigue and weakness
d. Urine output 580 mL last shift
The nurse is developing a care plan from a b. Risk for infection related to slow healing graft donor site
client in the acute phase of a burn injury.
Which of the following would be the priority
nurse diagnosis for this client?
a. Risk for falls r/t contracture of
burnedextremities
b. Risk for infection related to slow
healinggraft donor site
c. Risk for denial r/t inability to
participatein dressing changes
d. Risk for ineffective coping r/t
inability tolook at burn wounds
When assessing a client who has suffered Erythema and blasters-superficial
a burn injury. The nurse classifies the
burn as superficial partial thickness burn
based on the observing which
characteristics? a. A. Painful, reddened
skin
b. Charred skin with milky-white areas.
c. Erythema and blasters-superficial
d. Erythema, pain, and swelling
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