Nurses’ Notes   2000: A 55- year-old female arrives to the emergency department via ambulance with bilateral superficial partial thickness and deep partial thickness burns to the front of both legs, the entire right arm and the chest from a house fire that occurred at 1800 today. Client weighs 242 lbs.   Fluid resuscitation started with Lactated Ringer’s IV in the emergency department. 2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Breath sounds clear.  Client begins to appear edematous. Doppler pedal pulses present. A triple-lumen subclavian central venous line has been inserted to monitor the client’s central venous pressure (CVP). 2105: Physician notified of vital signs and output. 500 mL bolus of LR ordered and infused. Vital Signs Time 2000 2100 2200 Temperature 37.8 C/100 F 37.5 C/99.5 F 35.6 C/96 F Heart rate 130 135 120 Respirations 28 32 36 Blood Pressure 88/58 80/54 98/60 Pulse oximeter 92 on 4L NC 98 on 100% NRB 89 on 100% NRB Pain 6/10 4/10 7/10 CVP   3 mmHg 5 mmHg Intake & Output Hour 2000 2100 2200 IV rate As ordered As ordered As ordered IV intake Started 689 mL 1813 mL Output   20 mL 125 mL   Based on the 2200 assessment findings above, what is the priority nursing action?  

The client presents to the emergency department with complains of shortness of breath after suffering 5 bee stings. It is determined the client is in a distributive shock, which of the following would be the treatment plan for this type of shock? Select all that apply

A patient is admitted to the emergency department after being rescued from a house fire. The nurse assesses the patient for signs of inhalation injury. Which of the following findings are indicative of possible inhalation injury? Select all that apply

After reviewing the information shown in the accompanying figure for a patient with cardiac tamponade, which information is most important to report to the health care provider?  Physical Assessment Hemodynamics VItal Signs Muffled heart sounds Cool clammy skin Restlessness Cardiac output (CO) 2 Systemic vascular resistance (SVR) 1400 Central venous pressure (CVP) 7 Blood pressure 90/53 (65) Heart rate 112 Oxygen saturation 90%

1.    Volume is decreased inside the compressor, causing an increase in pressure and _____.

The nurse cares for a 55-year-old female admitted to the burn unit following a house fire.  Nurses’ Notes   2000: A 55- year-old female arrives to  the emergency department via ambulance with bilateral superficial partial thickness and deep partial thickness burns to the front of both legs, the entire right arm and the chest from a house fire that occurred at 1800 today. Client weighs 242 lbs.  Fluid resuscitation started with Lactated Ringer’s IV in the emergency department. 2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Breath sounds clear.  Client begins to appear edematous. Doppler pedal pulses present. A triple-lumen subclavian central venous line has been inserted to monitor the client’s central venous pressure (CVP). Vital Signs   Time 2000 2100   Temperature 37.8 C/100 F 37.5 C/99.5 F   Heart rate 130 135   Respirations 28 32   Blood pressure 88/58 80/54   Pulse oximeter 92 on 4L NC 98 on 100%  Non-Rebreather (NRB)   Pain 6/10 4/10   CVP   3 mmHg   Intake & Output   Hour 2000 2100   IV rate As ordered As ordered   IV intake Started 689 mL   Output   20 mL   Which five client findings should the nurse report to the healthcare provider immediately? Select all that apply

A patient is being treated in the emergency department for shock of unknown origin. The first action by the nurse should be to

A nurse is caring for a patient who sustained a 45% TBSA burn 24 hours age. The client is exhibiting signs and symptoms of a pulmonary embolism. Which of the following factors contribute to the elevated risk of venous thromboembolsim (VTE) in burn patients? Select all that apply

A client is brought to the emergency room after being struck by lightning during a thunderstorm. There is an entrance wound on the client’s left shoulder and an exit wound on the right calf. The nurse should prioritize which of the following interventions? Select all that apply

A nurse is providing care for a patient with a superficial partial thickness burn to the right lower extremity. What nursing intervention is essential to prevent burn wound conversion?