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ANS: All local hospitals prepare to receive casualties.
ANS: Designate specific family areas that are staffed with counselors.
implement first ANS: Place a disaster tag securely on each victim.
following clients would the nurse identify with a red tag ANS: -A client whose vital signs include respirations at 22 breaths/min , pulse at 120 beats/min, and blood pressure at 85/52 mmHg. -A client with a pulsating femur wound. -A client with full thickness burns over 50% of the body.
ANS: Priority 1, Color Red.
important for the nurse to implement upon admission?- : Establish and maintain an open airway.
affecting his epidermis and dermis. Based on this assess- ment, which finding best describes the James' burns ANS: Partial thickness or second degree burns.
time the fluid is given to the client ANS: The nurse admin- isters the first half of the fluid from the time the burn occurred over 8 hours, and the second half over the following 16 hours.
ANS: Inform the officer that he must first speak to James' parents.
concerning this request ANS: Allow the police officer access to the requested medical records.
electrolytes from intravascular to extravascular spaces, which can lead to cardiovascular collapse. Which assessment relates most directly to a diagnosis of Curling's ulcer ANS: Assess the gastric aspirate for pH and blood the color of coffee grounds.
discusses how to best meet James' growth and development needs. Which interventions will meet James' needs during his hospital stay?- : -Provide James with cds and video games. -Obtain a laptop computer with internet access for James.
ANS: "If I'm concerned that it will affect your care, then I will have to tell someone."
ANS: "Have you thought about how you would kill yourself?"
ANS: Ensure meticulous hand wash- ing before and after James' care.
ANS: Outline the drainage on the dressing and write the date and time.
ANS: "The skin will probably be taken from your son's back."
is experiencing pain at the donor site, as well as the graft site, rated as a 6 out of 10 on the pain scale, even though he is receiving morphine via patient-controlled analgesic (PCA) pump. There is a prescription for morphine 4 mg IV push every 4 to 6 hours PRN for break through pain.The nurse determines that James could use a PRN dose of morphine for his break through pain. The morphine is in a vial labeled 10 mg/mL. How much morphine will the supervising nurse administer to James? (Enter the numerical value only. If rounding is required, round to the nearest tenth.): 0.
site is moist and intact. What action should the nurse implement ANS: Document this assessment in James' chart.
ANS: "The pressure stocking will help prevent scarring that could occur while the burn is healing."
ANS: Refer James to an adolescent burn support group.
ANS: Determine if there is a family member who can stay with James during the day.
ANS: Provide specific written instructions for James' home care before releasing him to go home.