Extract:

Question 1 of 5

The nurse is assessing a client for Brudzinski's sign as part of their neurologic assessment. Which of the following are appropriate actions by the nurse when performing this technique? (SELECT ALL THAT APPLY)

A. Bend the client's head toward their chestB. Ask the client to extend both arms above their headC. Place the client in supine positionD. The nurse will place a hand behind the client's headE. Assist the client to bend their knee 90 degrees

Correct Answer: A,C,D

Rationale: Flexing the neck in a supine position with a hand behind the head tests for Brudzinski's sign.

Question 2 of 5

The nurse is caring for a client, with no other pertinent medical history, who was burned over 70% Total Body Surface Area (TBSA) and weighs 70kg. Using the Parkland Formula, calculate the amount of intravenous fluid required in the first 8 hours after the burn.

Correct Answer: B

Rationale: Using the Parkland Formula:
Total fluid requirement = 4 Ã— 70 kg Ã— 70% TBSA = 19,600 mL (total for 24 hours). Fluids in first 8 hours = 19,600 mL Ã· 2 = 9,800 mL.

Question 3 of 5

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 client demonstrating a new onset of chest pain, low back pain, tachycardia and anxiety. The nurse's immediate intervention is

A. Stop transfusion, run normal saline.B. Administer morphine IV.C. Administer epinephrine IMD. Continue to monitor the infusion.

Correct Answer: A

Rationale: Symptoms suggest an acute hemolytic transfusion reaction, requiring immediate cessation of the transfusion and administration of normal saline.

Question 4 of 5

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

A. Causative agent and duration of exposureB. Depth of burnC. Anatomical location of burns on the bodyD. Total Body Surface Area (TBSA) percentageE. Time of day burn occurred

Correct Answer: A,B,C,D

Rationale: Causative agent, depth, location, and TBSA are critical for assessing burn severity.

Question 5 of 5

The nurse is caring for a burn victim during the emergent phase. Assessment findings include white charred leathery wounds over 72% Total Body Surface Area (TBSA). Following intubation and mechanical ventilation, what is the priority intervention?

A. Fluid resuscitationB. Transfer to a burn centerC. Application of sterile dressingsD. Administer morphine 8mg IV.

Correct Answer: A

Rationale: Fluid resuscitation is critical to restore intravascular volume and prevent hypovolemic shock in severe burns.