A nurse is caring for a client in a medical-surgical unit

A nurse is caring for a client in a medical-surgical unit.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition:

Transfusion-associated circulatory overload (TACO)

Actions the Nurse Should Take:

Stop transfusion (D): This is crucial to prevent further fluid overload and worsening symptoms.
Administer furosemide (C): Furosemide is a loop diuretic that can help remove excess fluid and alleviate symptoms of fluid overload.

Parameters to Monitor:

Weight (B): Monitor weight to assess for fluid retention and overload.
Respiratory rate (C): Monitor respiratory rate closely for signs of respiratory distress such as dyspnea and increased effort.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

A. Endolymph fluid provides protection to the structures of the inner ear. - Endolymph is found within the inner ear, specifically in the membranous labyrinth, and plays a crucial role in hearing and balance.

B. Sanguineous fluid provides protection to the structures of the inner ear - Sanguineous fluid refers to blood or fluid containing blood. It is not present in the inner ear.

C. Aqueous humor provides protection to the structures of the inner ear - Aqueous humor is the fluid found in the eye, not the ear.

D. Vitreous humor provides protection to the structures of the inner ear - Vitreous humor is found in the eye, not the ear.

A. Airway obstruction B. Paralytic ileus C. infection D. Fluid imbalance

Correct Answer is A

Explanation

A. Airway obstruction - Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and potential inhalation injury. Ensuring a patent airway is the priority as it is critical for oxygenation and survival.

B. Paralytic ileus - While possible, a paralytic ileus is not an immediate life-threatening condition compared to airway obstruction.

C. Infection - Infection is a significant concern in burn patients, but it is a secondary priority after securing the airway.

D. Fluid imbalance - Fluid management is crucial in burn care, but securing the airway takes precedence due to the immediate risk to life from airway obstruction.

A nurse is caring for a client in a medical-surgical unit.

Exhibits

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a group of clients about the specific types of fluids that protect the structures of the inner ear. Which of the following statements should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is A

Explanation

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