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A 5-year-old child presents to the emergency department with bruises to the upper arms and buttocks in various stages of healing and multiple small, clean, round burns to the back. There are no abnormalities found based on the pediatric assessment triangle or primary survey. Which of the following is the priority nursing intervention? A.Report your suspicion of maltreatment in accordance with local regulations B.Apply ice to the bruises and provide wound care C.Engage in therapeut...

You are caring for a patient who was thrown from a bike and was not wearing a helmet. While performing the head-to-toe assessment, you note clear drainage from the right ear. Which of the following is the most appropriate next step? A. Clean the ear with a cotton-tipped applicator. B. Pack the ear with gauze. C. Notify the physician D. Document and continue the exam. - ANSWER--C. Notify the physician A patient is brought to the emergency department of a rural hospital...

Answer: C A) The driver of the vehicle collides with the steering wheel B) the vehicle collides with a tree C) the aorta is torn at its attachment with the ligamentum arteriosum D) the airbag deploys and strikes the front seat passenger *** Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? Answer: c a) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) to gauge end-organ pe...

Why is a measure of serum lactate obtained in the initial assessment of the trauma patient? Answer: c correct answera) to measure oxygenation and ventilation b) to quantify the base deficit for the adequacy of cellular perfusion c) *to gauge end-organ perfusion and tissue hypoxia ** d) to determine the underlying cause of shock A trauma patient is restless and repeatedly asking "where am I?" vital signs upon arrival were BP 100/60 mm Hg, HR 96 beats/min, and RR 24 breaths/min. ...

At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing? A. "I am cold." B. "I have a backache." C. "I feel dizzy." D. "I am nauseous." Answer: C Explanation: (A) Cold is not a symptom of hyperventilat...

A nurse is preparing to administer Xylocaine to a client. The medication is packaged in an ampule. What should the nurse do with the unused portion of the Xylocaine? Discard any unused portion of the Xylocaine in the ampule. A couple with young children asks the nurse about the factors that contribute to a strong family unit. What instruction is of the highest priority for the nurse to provide to the parents? Participation from both parents in child rearing is important. Know the...

1. The nurse shows a teenager how to use a metered dose inhaler of ipratropium (Atrovent). Which statement, if made by the patient to the nurse, indicates teaching is effective? 1. “I should use this medicine to stop the coughing that leads to an asthma attack” 2. “I should use this medicine if I begin to have an asthma attack” 3. “I should use this medicine right after I have an asthma attack” 4. “I should use this medicine to prevent an asthma attack” CORRECT>&...

The nurse is monitoring a patient receiving oxygen therapy. Which assessment is a priority to ensure effective therapy? -correct-answer-Assess for proper placement of the nasal cannula The LPN is caring for a teenager that was rushed to the emergency room (ER) following her mother's complaint her teen has been irritable, barely eats/drinks, and has had diarrhea for the past three days. The teenagers respiratory rate is elevated. PAO2 is 99% and skin is dry. The physician orders ar...

A nurse is caring for elderly patients in an assisted-living facility. Which of the following effects of aging should the nurse consider when performing a urinary assessment? Decreased bladder contractility may lead to urine retention and stasis, which increase the likelihood of urinary tract infection. The nurse is caring for a patient who is not allowed oral intake of fluid or food. When evaluating this patient's urinalysis, what would the nurse anticipate? An increased urine spe...

What does fluid overload do to the body What is an isotonic solution? What does an isotonic fluid do to body? Where does isotonic fluid go?