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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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

- Choice A: No Understanding

- Reason: An echocardiogram is a non-invasive procedure that uses ultrasound waves to create images of the heart.

- Choice B: Understanding

- Reason: Parents can indeed show their child a movie or read a book during the procedure as it helps keep the child calm and still, which is conducive for a transthoracic echocardiogram².

- Choice C: No Understanding

- Reason: An echocardiogram is generally not a painful procedure. It is non-invasive and involves placing a transducer on the chest to capture images of the heart².

- Choice D: Understanding

- Reason: The echocardiogram will indeed produce an image of the structure of the heart, which is essential for diagnosing and assessing conditions like VSD.

- Choice E: Understanding

- Reason: Echocardiography uses sound waves to produce images of the heart, which can show how well blood is moving through the heart and heart valves.

A. Advise the UAP to resume positioning the client on schedule. B. Encourage the UAP to provide comfort care measures only. C. Assume total care of the client to monitor neurologic function. D. Assign a practical nurse to assist the UAP in turning the client.

Correct Answer is A

Explanation

Choice A: Advise the UAP to resume positioning the client on schedule.

Reason: Turning the client from side to side is a critical nursing intervention to prevent complications such as pressure ulcers, pneumonia, and other issues related to immobility. Even though the client has a “Do Not Resuscitate” (DNR) order, it does not mean that comfort and preventive care measures should be stopped. The nurse should advise the UAP to continue with the scheduled positioning to ensure the client’s comfort and prevent further complications.

Choice B: Encourage the UAP to provide comfort care measures only.

Reason: While providing comfort care is essential, it does not mean that other necessary interventions, such as turning the client, should be neglected. Comfort care measures should include turning the client to prevent pressure ulcers and other complications. Therefore, this option is not the best choice as it may lead to neglecting important preventive care.

Choice C: Assume total care of the client to monitor neurologic function.

Reason: Assuming total care of the client is not practical and may not be necessary. The nurse should delegate tasks appropriately and ensure that the UAP is performing their duties correctly. Monitoring neurologic function is important, but it does not require the nurse to take over all aspects of the client’s care.

Choice D: Assign a practical nurse to assist the UAP in turning the client.

Reason: While assigning a practical nurse to assist the UAP might be helpful, it is not necessary if the UAP can resume the scheduled positioning on their own. The nurse should first advise the UAP to continue with the scheduled positioning before considering additional assistance.

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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?

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Naxlex Comprehensive Predictor Exams

Patient Data Exhibits After the physician orders the echocardiogram, the nurse educates the parents about the procedure. For each statement below, indicate whether it shows understanding or a lack of understanding by the parents.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Correct Answer is A

Explanation

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