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%.   Which of the following assessment information would require immediate intervention?

A patient is admitted to the ED with suspected alcohol intoxication. The ED nurse understands the high incidence of multi-substance use and prepares to perform which action to effectively develop a plan of care for the client? 

A nurse is caring for a client brought into the emergency room with a neck injury after diving into a lake. Upon assessment his blood pressure is 85/54, heart rate is 53 beats per minute, respirations 10 breaths per minute, oxygen saturation is 94% and his skin is warm and dry. Which action would the nurse perform first?

An emergency department nurse has just admitted a client with a burn. The burn area is the anterior upper chest and left anterior arm. Using the rule of nine, what would be the extent of the burn injury?    

A nurse educator is providing education to new nurses in the burn unit. The nurse understands that burn wounds are grafted to ensure recovery and explains the care for a graft involves which action?

The patient is brought to the ED by friends who report, “He probably overdosed on xanax.” The patient has a decreased level of consciousness and a decreased gag reflex; his face and chest are covered with emesis; he demonstrates spontaneous sonorous respirations; and pulse oximetry is 87% on room air. What type of airway management does the nurse expect this patient to receive?

 The nurse is admitting a client who is suspected of having heat stroke. What assessment finding would be most consistent with this diagnosis?

 A client with multiple injuries is brought to the emergency department by ambulance. The client has had his airway stabilized and is breathing on their own. The nurse does not see any active bleeding, but should suspect internal hemorrhage based on what finding? 

A patient has a new prescription for insulin aspart. As you are completing medication education with this patient, you should include which statement? 

You are educating a client about their new medication, levothyroxine. Which finding, if noted in your assessment, might indicate an adverse effect is developing?