The nurse is educating a patient receiving IV heparin about potential side effects. Which statement by the patient indicates a need for further teaching? 

When managing a patient on mechanical ventilation, which action should the nurse prioritize? 

A client with head and neck cancer is receiving radiation therapy and reports difficulty swallowing. What is the priority nursing intervention?  

A chest tube is placed for a patient with pneumothorax. Which of the following is a critical action in managing the chest tube? 

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 second and third degree burns to the front lower extremities from a house fire that occurred at 1800 today. Burns estimated at 36% of total body surface area. Client weighs 220 lbs.   2100:  Admitted to the burn unit. Vital signs as noted. Morphine sulfate given for pain.  Wound care was provided by the nurse.  Breath sounds clear.  Bilateral +2 pitting edema was noted in the lower extremities. Doppler pedal pulses present.  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  95 on 4L NC  92 on 4L NC  Pain  6/10  4/10  Intake & Output     Fluid resuscitation order: 4 mL Ringer’s lactate x kilogram weight x body surface burned. Give the first half within the first 24 hours and the remaining over the next 16 hours.     Hour  2000  2100  Fluids in the field  1200 mL/hr  1200 mL/hr  Output    20 mL        What should the nurse set the IV pump at to deliver the first 8 hours of fluid resuscitation for this patient according to the ordered fluid resuscitation order? ____  mL/hr   

A client has a central venous catheter (CVC) inserted for long-term antibiotic therapy. The nurse is reviewing the care plan to reduce the risk of central line–associated bloodstream infections (CLABSIs). Which nursing action is most appropriate to include in the plan?

A client has partial-thickness burns on the entire anterior trunk and the anterior right arm. Using the Rule of Nines, what is the total percentage of body surface area burned? 

A client with severe burns presents with signs of hypovolemic shock. What is the most important initial assessment the nurse should perform? 

A 68-year-old client with a history of congestive heart failure presents to the emergency department with acute pulmonary edema. The nurse performs an initial assessment and notes the following: respiratory rate 32 breaths/min, bilateral crackles on auscultation, oxygen saturation of 85% on room air, and extreme anxiety. Which of the following interventions should the nurse prioritize to manage this client’s condition? Select all that apply and provide rationale for your choices.

A client is admitted with a pneumothorax and has a chest tube inserted. Which intervention should the nurse perform to ensure the chest tube is functioning properly?