A nurse is caring for a patient on a ventilator in the critical care unit. The nurse understands which of the following are common manifestations of ventilator- associated pneumonia?

Low blood pressure and bradycardia

Nausea and vomiting

Weight gain and hypertension

Fever, elevated WBC count, and pulmonary infiltrates

Answer and Explanation

The Correct Answer is D

A. Low blood pressure and bradycardia are not typical early signs of ventilator-associated pneumonia (VAP).
B. Nausea and vomiting are not primary manifestations of VAP.
C. Weight gain and hypertension are unrelated to VAP.
D. Fever, elevated white blood cell count, and new or worsening pulmonary infiltrates on chest X-ray are classic signs of ventilator-associated pneumonia.

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Correct Answer is A

Explanation

Each leg (front + back) accounts for 18% TBSA × 2 legs = 36%.

Each arm (front + back) accounts for 9% TBSA × 2 arms = 18%.

Total burned TBSA = 36% (legs) + 18% (arms) = 54%.

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

Correct Answer is D

Explanation

A. Infection is a significant concern in burn clients but is not the immediate life-threatening priority in the initial phase of care.
B. Fluid imbalance is a critical issue during burn management, especially in the resuscitation phase, but airway management takes precedence.
C. Paralytic ileus can occur due to stress and decreased perfusion but is a lower priority compared to airway compromise.
D. Airway obstruction is the top priority in clients with burns to the head, neck, and chest, due to the risk of inhalation injury, swelling, and respiratory compromise. Airway patency must be ensured immediately to prevent life-threatening complications.

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A nurse is caring for a patient on a ventilator in the critical care unit. The nurse understands which of the following are common manifestations of ventilator- associated pneumonia?

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Naxlex Comprehensive Predictor Exams

A nurse in an emergency department is caring for a client who has burns on the front and back of both his legs and arms. Using the rule of nines the nurse should document burns to which percentage of the client's total body surface area (TBSA)?

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 D

Explanation

Which of the following statements is true about smoke inhalation injuries?

Using the Parkland formula, calculate the fluid rate per hour for a patient with 30% TBSA burn, weighing 75 kg, during the first 8 hours of fluid resuscitation.

Which of the following is true regarding the femoral access for an arterial or pulmonary catheter?

What is wedge pressure?

A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?

When assessing for adequate circulation prior to inserting an arterial line, the nurse should perform which of the following actions?

What is the appropriate technique for suctioning a tracheostomy tube?

Which of the following is a primary purpose of hemodynamic monitoring?