20. After endotracheal suctioning, the nurse notes that the intracranial pressure (ICP) for a client with a traumatic head injury has increased from 14 to 17 mmHg. Which action should the nurse take first?
30. A client admitted with dermal ulcers who has a history o…
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?
58. Priority nursing management for a client who has develo…
58. Priority nursing management for a client who has developed multi-organ dysfunction syndrome (MODS) would include which intervention.
29. The nurse should monitor the child for which finding to…
29. The nurse should monitor the child for which finding to help confirm the diagnosis of lead poisoning? (Select all that apply)
44. The nurse is assessing a client with ecchymosis for a ba…
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?
48. The nurse is caring for a client who has a head injury a…
48. The nurse is caring for a client who has a head injury and fractured right arm after being assaulted. He is examined by the primary health care provider (PHCP) and the CT scan identifies an acute subdural hematoma. Which assessment information requires rapid action by the nurse?
38. Health promotion for a client with spinal cord injury i…
38. Health promotion for a client with spinal cord injury include implementation of which measure? Counseling Education Encourage seat belts Encourage helmets Identify those that are at high-risk
45. After the emergency department nurse has received a stat…
45. After the emergency department nurse has received a status report on the following clients who have been admitted with head injuries, which client should the nurse assess first?
60. The HCP has prescribed Dopamine at 10mcg/kg/min for a cl…
60. The HCP has prescribed Dopamine at 10mcg/kg/min for a client who has a diagnosis of Septic shock. The medication is supplied as Dopamine 400mg in 250ml of D5W. The client weighs 242 lbs. How many mL/hr will the Dopamine infuse? (Round to the nearest tenth)
35. A client with massive trauma and possible spinal cord in…
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?