A nurse is providing care for a client with severe burns.

The client’s vital signs at 0820 are as follows: Blood pressure 140/80 mm Hg, Heart rate 110/min, Respiratory rate 25/min, Sa 98% on room air, Temperature 36.1 C (97° F). Which of the following interventions should the nurse consider? (Select all that apply.)

Cool the burn with ice water.

Administer opioid analgesics.

Administer systemic antibiotics.

Administer benzodiazepines for anxiety management.

Position the head of the bed flat.

Answer and Explanation

Correct Answer : B,C,D

Choice A rationale
Cooling the burn with ice water is not recommended for a client with severe burns. Ice water can cause hypothermia and further damage the skin.
Choice B rationale
Administering opioid analgesics is a key intervention for a client with severe burns. Pain management is a critical aspect of burn care.
Choice C rationale
Administering systemic antibiotics is often necessary for a client with severe burns. Burn injuries can compromise the skin’s protective barrier, making the client susceptible to infections.
Choice D rationale
Administering benzodiazepines for anxiety management can be beneficial for a client with severe burns. The experience of having a severe burn and undergoing treatment can be extremely stressful.
Choice E rationale
Positioning the head of the bed flat is not typically recommended for a client with severe burns. Elevating the head of the bed can help reduce swelling and improve respiratory function. Septic shockSeptic shock Explore

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Correct Answer is A

Explanation

Choice A rationale
Epinephrine is the first-line treatment for anaphylactic shock. It works by constricting blood vessels to increase blood pressure, relaxing smooth muscles in the lungs to reduce wheezing and improve breathing, stimulating the heart, and reducing hives and swelling around the face and lips.
Choice B rationale
Dexamethasone is a corticosteroid that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by reducing inflammation.
Choice C rationale
0.9% Normal Saline is a type of intravenous fluid that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by increasing fluid volume in the body to help maintain blood pressure.
Choice D rationale
Dobutamine is a medication that can be used to treat anaphylactic shock, but it is not the first-line treatment. It works by stimulating the heart muscle to increase cardiac output, which can help maintain blood pressure.

A. Maintain the client on bed rest. B. Encourage the client to drink 3 L of fluids per day. C. Provide the client a high protein diet. D. Tell the client to expect a decrease in urine output.

Correct Answer is B

Explanation

Choice A rationale
Maintaining the client on bed rest is not a recommended intervention for a client with urolithiasis. Bed rest does not facilitate the passage of stones and can lead to complications such as deep vein thrombosis.
Choice B rationale
Encouraging the client to drink 3 L of fluids per day is the correct intervention. Increased fluid intake can help flush out the urinary system and facilitate the passage of stones. It also helps prevent new stone formation by diluting the substances that lead to stones.
Choice C rationale
Providing the client a high protein diet is not a recommended intervention for a client with urolithiasis. High protein diets can increase the amount of calcium and uric acid in urine, which can contribute to stone formation.
Choice D rationale
Telling the client to expect a decrease in urine output is not a recommended intervention for a client with urolithiasis. Decreased urine output can lead to urinary stasis and contribute to stone formation.

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing orders for a patient in anaphylactic shock. Which medications should the nurse plan to administer first?

Correct Answer is A

Explanation

A nurse is contributing to the plan of care for a client who has urolithiasis. Which of the following interventions should the nurse include in the plan?

Correct Answer is B

Explanation

The nurse is about to administer 1 liter (1000 mL) of 0.9% NS over 2 hours intravenously to a patient in shock. What rate should the nurse set on the infusion pump?

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