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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: Measuring urinary output is important for monitoring renal function, especially when using medications like morphine, but it is not the most critical intervention in this context.

Choice B reason: Administering the oral analgesic before discontinuing the PCA allows for the medication to take effect, preventing breakthrough pain and addressing the client's fear of pain.

Choice C reason: Monitoring for a depressed respiratory rate is crucial when a patient is on morphine, but the priority is to manage pain effectively as the client transitions to oral analgesics.

Choice D reason: Education on dietary needs is important for long-term recovery, but immediate pain management is a higher priority in the postoperative period.

Correct Answer is []

Explanation

The nurse should:

Raise the head of the bed to aid in breathing.
Change to a face mask for oxygen delivery to address hypoxia.

The nurse should monitor:

Lung sounds to assess the progression of pneumonia.
Oxygen saturation to ensure the patient is receiving adequate oxygen.

Choice A reason: Increasing IV fluids is important in the care of pneumonia patients to prevent dehydration, especially if the patient has fever and increased respiratory rate which can lead to fluid loss. However, in this case, the patient’s blood pressure is stable, and there is no indication of dehydration, so this would not be the immediate action.

Choice B reason: Raising the head of the bed can help improve the patient’s breathing by reducing pressure on the chest and aiding in lung expansion. This is a standard care practice for patients with respiratory difficulties and is particularly beneficial for those with pneumonia to facilitate easier breathing.

Choice C reason: Bronchodilator nebulization can help open airways and improve breathing in patients with respiratory conditions. While it may be used in the treatment of pneumonia, it is not the primary intervention for hypoxia.

Choice D reason: Changing to a face mask for oxygen delivery is a critical intervention for a patient experiencing hypoxia. The patient’s oxygen saturation is 88% on 2 L/minute via nasal cannula, which is below the normal range of 95-100%3. A face mask can deliver higher concentrations of oxygen, which is necessary to address the patient’s hypoxia.

Choice E reason: Calling a rapid response team is necessary if the patient’s condition is deteriorating rapidly and requires immediate medical intervention. In this scenario, while the patient is hypoxic, there is no indication of acute decompensation that would necessitate a rapid response team at this moment.

Choice F reason: Pneumothorax, or collapsed lung, would present with sudden chest pain and shortness of breath. The patient’s history and symptoms are more consistent with pneumonia rather than pneumothorax.

Choice G reason: Hypoventilation refers to decreased breathing efficiency, leading to increased levels of carbon dioxide in the blood. While the patient does have difficulty breathing, the primary issue seems to be the impaired oxygen exchange due to pneumonia, rather than hypoventilation.

Choice H reason: Atelectasis is the collapse of part of the lung, which can occur after surgery or with bedridden patients. This patient’s symptoms are more indicative of an infectious process rather than atelectasis.

Choice I reason: Hypoxia is a condition where the body or a region of the body is deprived of adequate oxygen supply. Given the patient’s low oxygen saturation level and bilateral lower lobe pneumonia, hypoxia is the most likely condition the patient is experiencing.

Choice J reason: Monitoring lung sounds is essential for assessing the effectiveness of treatment and progression of pneumonia. Diminished lung sounds can indicate poor air movement due to the infection.

Choice K reason: Changes in the level of consciousness can indicate worsening hypoxia and should be monitored closely. A decrease in consciousness can be a sign of inadequate brain oxygenation.

Choice L reason: Oxygen saturation is a direct measure of the patient’s respiratory status and should be monitored to assess the effectiveness of oxygen therapy and overall progression.

Choice M reason: While heart rhythm should be monitored in all patients, it is not the most specific parameter for assessing the progression of pneumonia or hypoxia.

Choice N reason: Temperature should be monitored to assess for fever, which can indicate infection or inflammation. However, it is not as directly related to respiratory function as oxygen saturation and lung sounds are in the context of pneumonia.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Correct Answer is B

Explanation

Correct Answer is []

Explanation

While conducting a physical assessment, a client with cirrhosis of the liver reports to the nurse having had a 5 lb (2.3 kg) weight gain within the last week. Which assessment finding correlates with the client's comment?

The nurse is teaching a client with early osteoporosis the importance of including vitamin D with calcium supplements. Which information is most important for the nurse to provide to encourage the client's compliance in the management of progressing osteoporosis?

The nurse manager is involved in agency restructuring. During this reengineering process, it is most important for the nurse to address which employee concern?

A nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

The nurse places an opioid patch on the chest of a client with intractable pain who also has obstructive sleep apnea (OSA). Which intervention is most important for the nurse to implement before leaving the client?

The nurse is completing an admission assessment on an older adult client with dehydration, failure to thrive, and who is immobile. The nurse reports to the healthcare provider that the client's right calf is red and swollen. The nurse should suspect which probable cause of these findings?

A nurse observes a practical nurse (PN) pouring warm water over the perineal area of a female client who has frequent urinary incontinence while the client is positioned on a bedpan. Which action should the nurse take?

One hour following cardiac catheterization via the left femoral site, a client reports feeling weak and dizzy. Assessment reveals that the client's dressing is dry and intact. Which action should the nurse take next?