A client is admitted to the hospital with burns and hypovolemia.
The nurse is preparing to start an intravenous (IV) infusion.
Which of the following IV fluids is the most appropriate for this client?
Normal saline (0.9% NaCl).
Half normal saline (0.45% NaCl).
Lactated Ringer’s.
D5W (5% dextrose in water).
The Correct Answer is A
Normal saline (0.9% NaCl).
Choice A rationale:
Normal saline (0.9% NaCl) is the most appropriate choice for a client with burns and hypovolemia.
This isotonic solution helps to restore intravascular volume and replace lost fluids.
It contains sodium chloride in a concentration similar to that of the body's extracellular fluid, making it effective for rehydration and replenishing electrolytes in hypovolemic patients.
Choice B rationale:
Half normal saline (0.45% NaCl) is a hypotonic solution with a lower sodium concentration than the body's extracellular fluid.
It is not the best choice for treating hypovolemia and burns because it may not effectively expand intravascular volume and may cause cellular swelling.
Choice C rationale:
Lactated Ringer's is an isotonic solution, but it contains additional electrolytes and lactate.
While it can be suitable for some fluid replacement needs, normal saline is preferred for burn patients because it has a simpler composition and is effective for volume resuscitation in cases of hypovolemia.
Choice D rationale:
D5W (5% dextrose in water) is a solution that primarily provides dextrose for energy, not suitable for hypovolemia and burns.
It can cause dilutional hyponatremia if used as the primary fluid in hypovolemic patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Administer electrolyte solutions or supplements as prescribed by the physician.
Rationale: While administering electrolyte solutions or supplements may be part of the treatment plan for a dehydrated child, it is not the initial action that the nurse should take.
The first step should be to assess the child's condition and monitor their response to treatment.
Choice B rationale:
Monitor the child’s response to treatment and adjust the plan accordingly.
Rationale: This is The correct answer.
Dehydration is a complex condition, and the nurse's initial action should be to closely monitor the child's response to treatment, which may include oral or intravenous rehydration.
By monitoring the child's vital signs, urine output, and clinical signs, the nurse can make real-time adjustments to the treatment plan.
Choice C rationale:
Collaborate with physicians, nutritionists, and other healthcare professionals to ensure comprehensive care.
Rationale: Collaboration with other healthcare professionals is important for the overall care of the child, but it is not the immediate action needed to correct electrolyte imbalances in a dehydrated child.
Monitoring and treatment adjustments come first.
Choice D rationale:
Assess the degree of dehydration based on clinical signs and symptoms.
Rationale: While assessing the degree of dehydration is important, it should not be the only action taken.
Monitoring the child's response to treatment and adjusting the plan is equally crucial.
Dehydration assessment is typically part of the initial evaluation, but ongoing monitoring is necessary to ensure the child's condition improves.
Correct Answer is C
Explanation
Choice A rationale:
Thirst and dry mouth are common signs of dehydration in adults, but in pediatric patients, especially infants, the signs are different.
Children may not be able to communicate their thirst effectively, and dry mouth might not be as noticeable as other signs.
Choice B rationale:
Rapid heart rate and low blood pressure are symptoms of shock, which can occur in severe dehydration.
However, these symptoms are not specific to dehydration and can be present in other conditions.
Sunken eyes and fontanelle in infants are more specific indicators of dehydration in pediatric patients.
Sunken eyes occur due to loss of tissue turgor, and a sunken fontanelle (the soft spot on an infant's head) is a late sign of dehydration.
Choice D rationale:
Lethargy and irritability can be signs of dehydration, but they are nonspecific and can occur in various pediatric conditions.
Sunken eyes and fontanelle, on the other hand, are more specific to dehydration, especially in infants.
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