A patient is unresponsive to verbal stimuli and exhibits an altered level of consciousness.

Which method should the nurse use to elicit a response from a painful stimulus?

A client has suffered a partial thickness second-degree burn injury of the chest, abdomen, and upper legs and is scheduled for hydrotherapy and debridement.

Which of these actions should the nurse take to effectively assist the patient?

The nurse is assessing tube feeding residual amounts and finds 10ml of residual.

The client is receiving 60ml/hr of feeding.

What action should the nurse take?

A nurse is caring for a client with partial-thickness and full-thickness burns on the head, neck, and chest.

What is the primary risk to the client?

A nurse is assisting with the care of a client.

• At 1600, the nurse administered an antibiotic as prescribed.
• At 1630, the nurse noted that the client’s bilateral breath sounds were clear and present throughout.
• The client reports itching on the chest and has urticaria over the chest and trunk.
• The client states they are having difficulty swallowing and feel as if there is a lump in their throat.
• The nurse hears bilateral breath sounds with scattered wheezing throughout.

What should the nurse do next?

A nurse is assisting in the care of a client who has developed cardiogenic shock.

Which pulse site should the nurse use when assessing circulation to the client’s brain?

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.)

A nurse is planning care for a client who has a peptic ulcer and a new prescription for sucralfate 2 gm administered twice daily.

When should the nurse plan to administer the medication?

A patient arrives at the emergency department with a stab wound to the chest.

The healthcare provider places two chest tubes to drain air and blood from the patient’s thoracic cavity.

Where should the nurse place the system?

A nurse leader is discussing possible continuing education opportunities with other staff members.

Which of the following actions should the nurse leader recommend to maintain clinical competence?

A nurse is attending to a client who has suffered a basal skull fracture.

During the morning hygiene care, the nurse observes a thin clear drainage coming from the client’s right nostril.

What should be the nurse’s immediate action?