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Which assessment tool is commonly used to evaluate a client's neurological status after a traumatic brain injury?
Glasgow Coma Scale
Which finding would contraindicate administration of thrombolytic therapy for ischemic stroke?
Evidence of hemorrhagic stroke
Which assessment finding may indicate shock in a trauma client?
Rapid pulse and decreased capillary refill
Which injury is commonly associated with blast injuries?
Tympanic membrane rupture
A burn client requires 18,072 mL of fluid over 24 hours. How much fluid should be administered during the first 8 hours?
1129 mL/hr
A client develops status epilepticus. Which medication should the nurse anticipate administering if benzodiazepines are ineffective?
Intravenous phenobarbital
A client presents with headache, nuchal rigidity, fever, and photophobia. What condition should the nurse suspect?
Meningitis
Which nursing action is most important when caring for a client after a seizure?
Document level of consciousness and health status
A nurse is caring for a client rescued from icy water. Which condition should be addressed first?
Hypothermia
An IV is infusing at 125 mL/hr with tubing calibrated at 15 gtt/mL. What is the flow rate in gtt/min?
31 gtt/min
Which finding may indicate early increased intracranial pressure?
Disorientation and restlessness
During a disaster triage event, which client should be treated first?
Client with blunt chest trauma and difficulty breathing
A client is experiencing respiratory distress. What is the nurse's first action?
Place the client in high Fowler's position
A client is admitted to the burn unit with full-thickness burns involving the entire right lower extremity and the entire right upper extremity. According to the Rule of Nines, what is the total body surface area (TBSA) affected?
36%
A medication order reads: Infuse 75 mL over 5 hours. What is the infusion rate?
15 mL/hr
A client is admitted with suspected heat exhaustion. What is the nurse's priority intervention?
Supplemental oxygen and monitor blood glucose
Which finding is commonly associated with hypothermia?
dry skin
Which complication is the most immediate concern following a severe traumatic injury?
Hemorrhage
A burn client weighs 61.2 kg and has burns over 36% TBSA. Using the Parkland Formula, what is the total fluid requirement for the first 24 hours?
8812.8 mL
A medication order reads: Infuse 50 mL over 10 hours. What is the infusion rate?
5 mL/hr
A client experiences a sudden loss of consciousness followed by tonic-clonic movements. What should the nurse suspect?
Seizure
Which intervention is inappropriate when caring for a client with heat stroke?
Giving milk to drink
According to disaster triage color coding, which color represents the deceased/expectant category
Black
A client has burns to the anterior trunk (18%), entire left arm (9%), and anterior left leg (18%). What is the estimated TBSA burned?
54%
How many units per hour should the nurse program into the infusion pump?
1546