An 80-year-old female presents to the ER with complaints of feeling more fatigued for the last three days and has had a fever the last 24 hours. She reports painful, burning sensation when she urinates as well as increased frequency of urination the last week. It has been 90 degrees this past week. She usually drinks 2-3 glasses of liquid a day and a cup of tea. Her daughter became concerned and brought her to the ER when she did not know what day it was. She has no history of confusion or diabetes. Labs were obtained. Which of the following lab results are RELEVANT that must be recognized as clinically significant to the nurse and requires immediate intervention? Select all that apply.

The triage nurse has four clients arrive in the emergency department at the same time. List the order in which the RN will assess these clients from first priority to last priority.

1. A 50-year-old female with moderate abdominal pain and occasional vomiting
2. A 35-year-old jogger with a twisted ankle, having a pedal pulse and no deformity.
3. An ambulatory dazed 25-year-old male with a bandaged head wound.
4. 4. An irritable 3-day old with a fever, petechiae, and nuchal rigidity.

It is the summer season, and patients with signs and symptoms of heat-related illness present in the ED. Which patient needs attention first?

Four victims of an automobile crash are brought by ambulance to the emergency department. The triage nurse determines that the victim who has the highest priority for treatment is the one with

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?

A nurse in an emergency room is caring for the client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

The nurse is administering crystalloid fluid replacement to an adult who has experienced severe fluid volume loss. The nurse expects to replace how much normal saline as ordered for each liter of volume loss in the client?

A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?

Cefazolin sodium 250 mg IV every 8 hours is ordered for your patient. You are to reconstitute with 2.5 ml sterile normal saline. After reconstitution the vial contains 225 mg/ml. How many ml will you administer per dose?

A 48-year-old gardener is driven in by friends after sustaining a chain saw inury to his left arm 10 minutes ago. He complains of severe pain, and blood is dripping from a towel that is wrapped around the patient's wrist. There is a large laceration over the wrist with active bleeding, and the hand distal to the injury is pale and absent of capillary refill. The patient is unable to extend the digits and sensation is absent in the third and fourth digits. The patient appears pale, cool and diaphoretic. Medications: none. Allergies: none. Last dT: 8 years ago PMH: none BP 96/60 Oral Temp 92.2 HR 110 RR 18 What is your triage priority?