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 B

Explanation

Choice B rationale

A respiratory rate of 20 breaths per minute is within the normal range for an adult, indicating that the patient’s respiratory status is stable. This would be an important indicator of the effectiveness of nursing care in a patient admitted with a lower respiratory infection.

Correct Answer is ["0.5"]

Explanation

Step 1: The available dose of epinephrine is 0.5 mg in 0.5 mL.

Step 2: The patient needs to administer 0.5 mg of epinephrine.

Step 3: Since the available dose is 0.5 mg/0.5 mL, for 0.5 mg of epinephrine, the patient should be taught to administer 0.5 mL1.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient admitted with a lower respiratory infection. After assisting the patient to bed and applying the prescribed oxygen, which finding would help the nurse evaluate the effectiveness of the nursing care?

Correct Answer is B

Explanation

The nurse is instructing a patient on how to administer 0.5 mg of epinephrine intramuscularly. If the available dose is 0.5 mg/0.5 mL, how many mL should the patient be taught to administer?

Correct Answer is ["0.5"]

Explanation

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