1. The nurse is caring for a patient with an arterial monitoring system. The nurse asses
the patient's noninvasive cuff blood pressure to be 70/40 mm Hg.The arterial blood
pressure measurement via an intra-arterial catheter in the same armis assessed by the nurse
to be 108/70 mmHg.What isthe best actionby the nurse?
Select one:
a. Frequent oropharyngeal suctioning
b. Side to side position changes
c. Range-of-motion to extremities
d. Frequent neurological assessments:
Answer d. Frequent neurological assessments
2. The nurse is caring for a burn-injured patient who weighs 154 pounds, andthe burn
injury covers 40% of his body surface area.The nurse calculates thefluid needs for the
first 24 hours after a burn injury using a standard fluid resuscitation formula of 4
mL/kg/% burn of intravenous (IV) fluid for the first 24 hours. The nurse plans to
administer what amount of fluid in the first 24 hours?
Select one:
a. 14000 ml
b. 2800 ml
c. 7000 ml
d. 11200 ml:
Answer a. 14000 ml
3. For patients with major burns, when should you start enteral feedings?Select one:
a. A few hours after the injury has occurred
b. Not until bowel sounds have returned
c. After the emergent phase of the injury
d. 2 to 3 days after the injury:
Answer c. After the emergent phase of the injury
4. After receiving the handoff report from the day shift charge nurse, whichpatient
should the evening charge nurse assess first?
Select one:
a. Patient with meningitis complaining of photophobia
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