Answer to Question 1
ANS: C
The initial nursing action for a patient in shock is to establish ventilatory support. Oxygen is provided, and the nurse carefully observes for signs of respiratory failure, which indicates a need for intubation. Cardiac monitoring would be indicated to assess the child's status further, but ventilatory support comes first. Oxygen saturation monitoring should be begun. Arterial blood gases would be indicated if alternative methods of monitoring oxygen therapy were not available. The Trendelenburg position is not indicated and is detrimental to the child. The head-down position increases intracranial pressure and decreases diaphragmatic excursion and lung volume.
Answer to Question 2
ANS: C
With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hours after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hours later. Vasodilation occurs, causing an increase in hydrostatic pressure.
The nurse assesses the patient's ability to use the walker correctly
The surgical nurse assists the client into the correct position
Turtle Surgery
An Action Potential
Action of an Osmoreceptor
Summary of Drug Action: Common Routes of Administration