When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

A high school football player is brought to the emergency department after collapsing at practice in extremely hot and humid weather, the rectal temperature is 104.9 degrees Fahrenheit. The nurse implements which priority intervention to control the client’s temperature? 

A nurse educator is providing education to new nurses in the burn unit. The nurse understands that burn wounds are grafted to ensure recovery. Care for a graft involves:

A patient is being cared for in the Neurological Intensive Care Unit following a spinal cord injury. Which of the following assessment findings indicate the patient may be experiencing spinal shock?

As the client begins the acute phase of a burn, cautious administration of fluid and electrolytes continues. The nurse understands this care is based on which physiological condition. Select All That Apply.

An ED nurse is triaging clients according to the Emergency Severity Index (ESI). When assigning clients to a triage level, the nurse will consider the clients’ acuity as well as what other variable?

An immunocompromised older adult has developed a urinary tract infection and the care team recognizes the need to prevent an exacerbation of the client’s infection that could result in urosepsis and septic shock. What action should the nurse perform to reduce the client’s risk of septic shock?

The nurse is caring for a client with a traumatic brain injury receiving dexamethasone (Decadron) 4 mg IV every 6 hours. The client’s vital signs are Temperature: 99.0°F BP: 160/90 HR: 120 Respirations: 16 O2 Sat: 95%. Yesterday the client weighed: 67.2 kg. Which of the following assessment information would require immediate intervention?

A client is brought to the ED with third-degree burns on his face, neck, and chest. Upon assessment, the client has shallow breathing, pulse oximetry of 90%, and is disoriented. The nurse prepares for which priority intervention? 

A nurse in the critical care unit is planning the care of a client who is being treated for shock. Which of the following statements best describes the pathophysiology of this client’s health problem?