c. obtain a central venous pressure
d. monitor the pulmonary artery pressure
- ANSWER>>c. obtain a central venous pressure
4. A nurse is assessing the depth and extent of a client who has severe burns to the
face, neck, and upper extremities. Which of the following factors is the first priority
when assessing the severity of the burn?
a. Age of the client
b. Associated medical history
c. Location of the burn
d. Cause of the burn
- ANSWER>>d. Cause of the burn
A client arrives at the emergency dept following an explosion at the chemical
plant. He has deep partial and full-thickness chemical burns over more than 25 %
of his body surface area. What is the nurse's priority intervention?
a. Initiate fluid resuscitation
b. Medication for pain
c. Administer antibiotics
d. Maintain a patent airway
- ANSWER>>d. Maintain a patent airway
A nurse is caring for a client who came the emergency dept reporting chest pain.
The provider suspects a myocardial infarction. While waiting for the laboratory to
report the client's troponin levels, the client asks what this blood test will show.
The nurse should explain that troponin is
a. An enzyme that indicates damage to brain, heart, and skeletal muscle
tissues
b. A protein whose levels reflect the risk for coronary artery disease
c. A heart muscle protein that appears in the bloodstream when there is
damage to the heart
d. A protein that helps transport oxygen throughout the body
- ANSWER>>c. A heart muscle protein that appears in the bloodstream when there is
damage to the heart
A nurse is assessing a client who has disseminated intravascular coagulation
(DIC). Which of the following should the nurse expect in the findings?
a. Excessive thrombosis and bleeding
b. Progressive increase in platelet production
c. Immediate sodium and fluid retention
d. Increased clotting factors
- ANSWER>>d. Increased clotting factors
A nurse is about to administer warfarin (Coumadin) to a client who has atrial
fibrillation. When the client asks what his medication will do, which of the
following is an appropriate nursing response?
a. It helps convert atrial fibrillation to sinus rhythm
b. Is dissolves clots in the bloodstream
c. It slows the response of the ventricles to the fast atrial impulses
d. It prevents strokes in clients who have atrial fibrillation
- ANSWER>>d. It prevents strokes in clients who have atrial fibrillation
A nurse in a cardiac care unit is caring for a client with acute heart failure. Which
of the following findings should the nurse expect?
a. Decreased brain natriuretic peptide (BNP)
b. Elevated central venous pressure (CVP)
c. Decreased pulmonary pressure
d. Increases urinary outpu
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