36.  In which order will the nurse take these actions when doing a dressing change for a partial-thickness burn wound on a client’s chest?  A. Apply sterile gauze dressing B. Document wound appearance C. Apply silver sulfadiazine cream D. Administer analgesic Morphine as prescribed E. Clean wound with saline-soaked gauze

55. The nurse is admitting a client with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the client’s nose. Which admission order should the nurse question?

30. A client admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, “I have a pounding headache and l feel sick to my stomach ” Which action should the nurse take first?  

4. The nurse estimates the extent of a burn using the rule of nines for a client who has been admitted with deep partial-thickness burns of the anterior right arm, entire left arm and anterior left leg. What percentage of the client’s total body surface area (TBSA) has been injured?  

34. A client with a T4 spinal cord injury asks the nurse if he will be able to be sexually active. Which initial response by the nurse is most therapeutic?

57.  The nurse is caring for a child with protracted vomiting, tachycardia, hypoglycemia and rash.  Reye syndrome is to be ruled out.  The nurse should provide education to the parent to avoid giving the child which medication ?

35. A client with massive trauma and possible spinal cord injury is admitted to the emergency department (ED). Which assessment finding by the nurse will help confirm a diagnosis of neurogenic shock?

15. A client has just arrived in the emergency department after an extensive electrical burn from exposure to a high-voltage current. Which of these prescribed interventions should the nurse implement first? 

54.  The nurse would provide what explanation to a client about a cervical traction device following a spinal cord injury?

44. The nurse is assessing a client with ecchymosis for a basilar skull fracture.  The nurse should assess which area for potential confirmation of this type of injury in the client?