A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Average urine output of 28 mL/hour.

Vesicular bibasilar breath sounds.

Inspiratory and expiratory bilateral crackles.

Central venous pressure of 12 mm Hg.

Answer and Explanation

The Correct Answer is C

The correct answer is: c. Inspiratory and expiratory bilateral crackles.

Choice A: Average urine output of 28 mL/hour

Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.

Choice B: Vesicular bibasilar breath sounds

Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.

Choice C: Inspiratory and expiratory bilateral crackles

Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.

Choice D: Central venous pressure of 12 mm Hg

Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.

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Free Nursing Study Resources

Correct Answer is ["A","B","D","F"]

Explanation

Choice A reason: Walking frequently during recovery is essential for preventing blood clots, improving circulation, and aiding in the healing process. It is recommended for patients to start with short, frequent walks and gradually increase the distance as tolerated. This helps to enhance physical activity and supports weight loss maintenance post-surgery.
Choice B reason: After bariatric surgery, patients are typically started on a clear liquid diet and then advanced to full liquids before progressing to pureed foods and eventually solid foods. This gradual progression is necessary to allow the stomach to heal and to avoid complications such as leaks or obstructions at the surgical site.
Choice D reason: Patients who have undergone bariatric surgery are at risk for nutritional deficiencies due to the reduced intake and absorption of nutrients. Therefore, taking prescribed vitamin and mineral supplements is crucial to prevent deficiencies and ensure adequate nutrition.
Choice F reason: Starting with room temperature water can help prevent discomfort and gastrointestinal symptoms that may occur when drinking cold fluids after surgery. Room temperature fluids are generally better tolerated in the immediate postoperative period.
Choice C reason: While weight loss is expected after bariatric surgery, it is not accurate to anticipate that weight loss will continue with a normal diet. Patients must adhere to a specific postoperative diet and lifestyle changes to ensure continued weight loss and avoid weight regain.
Choice E reason: Ovulation and fertility can be affected by significant weight loss; however, it is not appropriate to expect an immediate return of ovulation post-surgery. Fertility changes can vary from person to person and may take time.
Choice G reason: Encouraging three large meals a day is contrary to the recommended dietary guidelines post-bariatric surgery. Patients are advised to eat small, frequent meals to accommodate the reduced stomach capacity and to prevent symptoms of dumping syndrome.
Choice H reason: Dietician appointments are not optional but are a critical component of postoperative care. Regular follow-up with a dietician ensures that patients receive personalized nutritional guidance and support as they adjust to their new dietary habits.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Choice A Reason: Decreasing portion sizes can help manage calorie intake and contribute to weight loss, which is beneficial for individuals with prediabetes or diabetes. Proper portion control is also essential for maintaining blood sugar levels within the target range.
Choice B Reason: Avoiding potassium-rich foods is not a standard dietary recommendation for diabetes management unless the individual has a specific condition like kidney disease that requires potassium restriction.
Choice C Reason: Eating only plant-based foods is not necessary for diabetes management. While a plant-based diet can be part of a healthy eating plan, it is not required for all individuals with diabetes.
Choice D Reason: Choosing a well-rounded diet ensures that all necessary nutrients are included, which is important for overall health and can help manage blood sugar levels. A balanced diet for diabetes should include a variety of foods from all food groups.
Choice E Reason: Eliminating carbohydrates is not recommended for diabetes management. Carbohydrates are a necessary part of a healthy diet, and individuals with diabetes should focus on the type and amount of carbohydrates consumed rather than eliminating them entirely.
Choice F Reason: Replacing refined sugar with honey or molasses is not necessarily beneficial for diabetes management. While these are natural sweeteners, they still affect blood sugar levels and should be used in moderation.

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A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits The nurse reviews the client data. What discharge education should the nurse provide? Select all that apply.

Correct Answer is ["A","B","D","F"]

Explanation

Patient Data Exhibits Review H and P and laboratory results. Drag from the Word Choices to complete the sentence. For the nutrition education portion of the visit, the nurse focuses on dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Patient Data Exhibits The nurse reviews the post catheterization orders. Which two orders would the nurse question?

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