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45. A patient is admitted to the burn unit with burns the upper body and head after a garage fire. Initially, wheezes are heard, but an hour later, the lung sounds are decreased ad no wheezes are audible. What isthe best action for the nurse to take? a. encourage the patient to cough and auscultate the lungs again b. Notify the HCP and prepare for endotracheal intubation c. Document the results and continue to monitor the patient’s resp. rate d. Reposition pt in high-Fowler’s position and reassess breath sounds 46. During the emergent phase of burn care, which nursing action will be most useful in determining whether the patient is receiving adequate fluid infusion? a. Check skin turgor b. Monitor daily weight c. Assess mucous membranes d. Measures hourly urine output 47. After receiving change-of-shift report, which of these patients should the nurse assess first? a. A patient with smoke inhalation who has wheezes and altered mental status b. A patient with full-thicknessleg burns who has a dressing change scheduled c. A patient with abdominal burns who is complaining of level 8 (0 to 10 scale) pain. d. A patient with 40% total body surface area (TBSA) burns who is receiving IV fluids at 500 mL/hr 48. The RN observes all of the following actions begin taken by a staff nurse who has floated to the unit. Which action requires that the RN intervene? a.The nurse uses latex gloves when applying antibacterial cream to a burn wound b. The float nurse obtains burn cultures when the patient has a temp of 101* F c. The float nurse administers PRN fentanyl (Sublimaze) IV to a pt 5 minutes before a dressing change d. The float nurse calls the health care provider for an insulin order when a nondiabetic pt has an elevated serum glucose 49) A client with cervical neck fracture is admitted to the intensive care unit. Which findings would the nurse recognize as indicative of spinal shock? A. Spastically, neuromuscular irritability, hyperreflexia B. Flaccidity and lack ofsensation below the level ofspinal cord lesion. C. Automatic dysreflexia with neurogenic bladder symptoms D. Muscular spasticity and loss of motor reflexes in all parts of the body below the level of spinal cord lesion. ****know T2-T3: paraplegic *************** 50) A client with T6 spinal cord injury is being discharged. The PT is concerned about autonomic dysreflexia. S/S include the following: A. Dialited pupils B. Sudden vomiting and diarrhea C. drop in BP and pulse D. Diaphoresis above the level of the lesion 51) A woman has been recently diagnosed with systemic lupus and shares with the nurse, I want to get pregnant, but I don’t know how I will tolerate pregnancy because I have lupus. Which response is best? A. Most women find that they feel better when they are pregnant B. How long have you been in remission? C. Women with lupusfrequently have slightly longer gestation D. Its best to become pregnant within the first 6 months of diagnosis 52. The nurse is assessing the patency of an arteriovenous fistula and suspects clotting in the fistula if which finding are noted? Select all that apply A. presence of a thrill on palpation over the fistula *B. Absence of a bruit on auscultation over the fistula C. Presence of a pulse in the extremity below the fistula *D. Complaints oftingling or discomfort in the extremity E. Warm hand and fingers in the extremity in which the fistula islocated. 53. Epoetin alfa (Epogen) is prescribed for a client diagnosed with chronic renal failure. The client asks the nurse about the purpose of the medication. The appropriate response would be which of the following? A. It is used to lower your blood pressure *B. It is used to treat anemia C. It will help to increase the potassium levels in your body D. It is an anticonvulsant medication given to all clients after dialysisto prevent seizure activity. 54. A client with and ECG reading showing sinus bradycardia has a blood pressure of 47/28 mmhg. Which drugs doesthe nurse expect the physician to order for this client? A. Lidocaine (Xylocaine) *B. Atropine sulfate C. Isoproterenol hydrochloride (Isuprel) D. Epinephrine 55. Chemical cardioversion is prescribed for the client with atrial fibrillation. The nurse who is assisting in preparing the client would expect that which medication specific for chemical cardioversion will be needed? A. Nitroglycerin B Nifedipine (Procardia) C Lidocaine (Xylocaine) *D.Amiodarone (Cordarone) 56. A nurse assesses a comatose, head-injured client and finds flexion of the arms, wrists, and fingers and adduction of the upper extremities. Which of the following describes these findings? A. Stroke B. Epileptic Seizure *C. Decorticate posturing D. Decerebrate posturing 57. The client diagnosed with ARDS istransferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? A Confirm that the ventilator settings are correct