1. The nurses calculating fluid resuscitation for young adult male who was

burned in a bloody accident at 1200 and is seen in the ER at 1400. The HCP

determines that the client has burn over 30% of his body, mainly over his

arms and chest. Using the Parkland formula for fluid resuscitation, the client

is to receive 7000 mL of fluid in 24 hours. Which goal should the nurse

establish for this clients plan of care?:

Answer:

By 2000, the client will have received 3500 mL of fluid

2. When caring for a client on a vent, which finding provides the greatest

indication that the client has an open airway?:

Answer:

Bilateral breath sounds can be auscultated

3. The nurse performs a prescribed a neurological check at the beginning

of the shift on a client who was admitted with a subarachnoid brain attack

(Stroke). The client's GCS is 9. What information is most important for the

nurse to determine?:

Answer:

The client's previous GCS score

4. An adult female with a history of type 1 diabetes has been vomiting for

the past 48 hours and is admitted to the ICU with DKA. Which assessment

finding warrants immediate intervention by the nurse?:

Answer:

Excessive thirst

5. A client admitted to the ICU after a colon resection with the formation of the

loop colostomy. The nurse determines that the clients abdominal dressing is

clean and dry. Vital signs are: HR: 130, temperature: 100, BP: 88/65, and urine

output of 10 mL/hr. What interventions should the nurse implement?:

Answer: