The nurse is caring for a patient with major bums Total Body Surface Area (TBSA) of 63%. The nurse understands that this patient is at the highest risk for the combination of which types of shock? (Select All that Apply.)

For the nurse to correctly classify the severity of a burn injury of a client, what must be assessed?
(Select All that Apply.)

What is included when the nurse performs the Glasgow Coma Score (GCS) on a client?

A client who has sustained blunt abdominal trauma is admitted to the ICU. Upon assessment the nurse notices the following vital signs: T-99F; HR- 148: RR-38; B/P-60/40. The client is diaphoretic and restless. The following selections are approved by the ICU physician. What would be the PRIORITY nurse's action?

Complete the following sentence with one of the options regarding the pathophysiology of this type of shock.
The nurse is caring for an elderly patient from a nursing home diagnosed with a urinary tract infection. The nurse assesses the patient as hypotensive, tachycardic, febrile, tachypneic, and with an altered mental status. The nurse understands that the pathophysiology of this type of shock is caused by___

The client admitted with sickle cell anemia crisis is being treated with a transfusion of 2 units of packed red blood cells (PRBC's) for a low hemoglobin. The cent demonstrating a new onset of chest pain. low back pain, tachycardia and anxiety. The nurse's immediate intervention is

The nurse is caring for a client who received a blunt force injury to zone II of the neck. Which assessment finding should the nurse report to the physician IMMEDIATELY?

The nurse is caring for a client who has an abdominal aortic aneurysm. The physician explains to the client that the aneurysm is small and that the client will be managed medically. Based on this information, it is most important that the nurse reinforces discharge teaching about:

An 85-year-old client is seen in the Emergency Department after a fall at home. The client is slightly confused, malnourished, and severely dehydrated. The client is reluctant to say what happened and her daughter constantly interrupts, not allowing the client to answer. Which of the following nursing interventions is a priority?

The nurse is caring for a client in the burn unit with burns to the head, neck, chest back left arm and hand following an explosion in their garage. Upon admission, the nurse auscultates wheezes throughout all lung fields and applies oxygen via non-rebreather. One hour later, upon reassessment, the patient is visibly anxious and short of breath, wheezes cannot be heard, lung sounds are decreased, voice is hoarse, and the client is coughing up gray sputum. What is the most appropriate nursing action?

A heparin IV bolus is ordered: 80 units per kilogram. The unit's pharmacist prepares & labels a dose of heparin that is 5600 units. What is the patient's weight in kilograms? _______________