A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The
nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

Fluid resuscitation due to capillary leaking.

Replacement of insensible water loss.

Extension of plasma until blood is available.

Restoration of electrolyte balance.

Answer and Explanation

The Correct Answer is A

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale

A. Dill pickles and black olives are typically high in sodium due to the pickling process. High sodium intake can exacerbate hypertension by increasing fluid retention and raising blood pressure.

B. Canned chicken broth often contains a high amount of sodium unless it is specifically labeled as low sodium or reduced sodium. Barley itself is a nutritious whole grain, but the sodium content in canned broth might counterbalance its benefits.

C. Tomato juice can be a good choice for someone with hypertension as long as it is low in sodium or sodium-free. Tomatoes are rich in potassium and other nutrients beneficial for heart health. Gluten-free crackers can be a healthy addition if they are low in sodium and made from whole grains.

D. Sweet potatoes are a nutrient-dense food high in potassium, fiber, and various vitamins and minerals. They are naturally low in sodium and are considered heart-healthy due to their potassium content, which helps counteract the effects of sodium on blood pressure.

Correct Answer is {"dropdown-group-1":"C"}

Explanation

Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing thromboembolism

Rationale

Prolonged immobility during labor and instrumental delivery are risk factors for venous thromboembolism (VTE) due to stasis of blood flow in the lower extremities. In addition, epidural anesthesia can contribute to venous stasis by impairing mobility and reducing the ability to feel discomfort or urgency to move.

The immediate postpartum period, especially after a prolonged labor and delivery, poses an increased risk of VTE due to hypercoagulability and vascular damage.

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Naxlex Comprehensive Predictor Exams

The nurse is teaching dietary modifications to a client with hypertension. Which product is the best selection to include as part of the client's lunch?

Correct Answer is D

Explanation

Exhibits The nurse is reviewing the chart. Select the condition from the choices below to fill in each blank in the following sentence. Based on the client's history and physical, the nurse notes that this postpartum client is most at risk for developing dropdown

Correct Answer is {"dropdown-group-1":"C"}

Explanation

After an unsuccessful resuscitation attempt, the nurse calls the family of the deceased. The family wish to see the body before it is taken to the funeral home. Which intervention(s) should the nurse take to prepare the body before the family enters the room? Select all that apply.

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

The charge nurse observes a new nurse preparing to irrigate an intravenous catheter. The new nurse brought a luer-lock tipped syringe. Which action should the charge nurse take?

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

The healthcare provider prescribes a low-fiber diet for a client with ulcerative colitis. Which food selection indicates to the nurse that the client understands the prescribed diet? A Baked potato with skin, raw carrots.

Exhibits Which other treatment(s) might be helpful for this client? Select all that apply.