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? By 2000, the client will have received 3500 mL of fluid When caring for a client on a vent, which finding provides the greatest indication that the client has an open airway? Bilateral breath sounds can be auscultated 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? The client's previous GCS score 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? Excessive thirst 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? Give a 500 mL IV fluid bolus challenge A client is admitted with syncopal episodes related to a third degree heart block. After the placement of a transcutaneous pacemaker, the nurse observes several episodes the pacemaker failure to sense. What action should the nurse take? Increase the sensitivity A client is receiving CPR. After systole is confirmed in two leads and sending the transcutaneous pacemaker, which IV medication should be administered? Epinephrine (adrenaline) A client has a chest tube connected to a closed water seal drainage system with suction. What equipment should the nurse always have available at the clients bedside? Occlusive dressing Bretylium 1 mg/min via infusion is prescribed for a client and ventricular tachycardia. The available solution is 500 mL D5W contains bretylium 1 gram. The nurse should program the infusion time to deliver how many mL/hr? 30 The client is receiving an infusion of nitroglycerin 100 mg and 500 mL D5W at 6 mL/hr. How many mcg/min of nitroglycerin is infusing? 20 A client arrives in the ER complaining of pain. What description of pain should prompt the nurse to suspect it originated in the myocardium? Produces chest heaviness with left arm pain Four days ago a chest tube was inserted into the second intercostal space of a client who has a pneumothorax. Today the nurse notes that there is no fluctuation in the