A client with 35% total body surface area deep partial-thick…
A client with 35% total body surface area deep partial-thickness burns from a house fire is admitted to the burn unit. Which risk factors place this client at highest risk for fluid, electrolyte, and acid-base imbalances? (Select all that apply)
Read DetailsA nurse assesses an 85-year-old client with advanced dementi…
A nurse assesses an 85-year-old client with advanced dementia following hip surgery. The client cannot verbally communicate pain intensity but exhibits restlessness, facial grimacing, and resists repositioning. The family states, “She’s always confused, so this is normal behavior.” Which nursing action demonstrates appropriate clinical judgment?
Read DetailsA nurse cares for a 72-year-old postoperative client on a me…
A nurse cares for a 72-year-old postoperative client on a medical-surgical unit. The client requires vital signs every 4 hours, IV antibiotics at 2200 and 0600, and has been awake since 0500. At 2100, the client requests pain medication and states feeling tired. Which intervention best promotes a complete sleep cycle?
Read DetailsA nurse assesses a 76-year-old client who fell at home. The…
A nurse assesses a 76-year-old client who fell at home. The client has weakness in lower extremities, unsteady gait, and a previous fall history. The home has multiple throw rugs and dim hallway lighting. Which clinical judgment process demonstrates the nurse’s synthesis of critical thinking elements?
Read DetailsA long-term care client initially presented with a sacral pr…
A long-term care client initially presented with a sacral pressure injury characterized by full-thickness skin and tissue loss with exposed muscle and bone. After several months of intensive wound care, the wound bed is now significantly smaller, healthy granulation tissue is abundant, and the tunneling has resolved. How should the nurse accurately describe the current state of this client’s pressure injury in the medical record?
Read DetailsA client recovering from a stroke has difficulty perceiving…
A client recovering from a stroke has difficulty perceiving objects on their left side and does not acknowledge people approaching from that direction. The nurse understands that this is an example of which sensory alteration?
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