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

Explanation

Choice A reason: After cardiac catheterization, monitoring the client's vital signs and telemetry pattern is crucial, especially when symptoms like weakness and dizziness are reported. These symptoms could indicate serious complications such as bleeding, arrhythmia, or cardiac tamponade. Monitoring vital signs can help detect hypotension, hemorrhage, or other hemodynamic instabilities. Telemetry is crucial for detecting arrhythmias that may require immediate intervention.

Choice B reason: Palpating and comparing pedal pulse volumes is an important step to assess for vascular complications such as thrombosis or embolism. However, it is not the immediate priority when a client reports systemic symptoms like weakness and dizziness, which could be signs of more serious conditions.

Choice C reason: Measuring post-procedure intake and output is part of routine postoperative care to ensure proper fluid balance. While important, it is not the most critical action to take when a client is experiencing acute symptoms that could indicate life-threatening complications.

Choice D reason: Removing the dressing and observing the site might be indicated if there is suspicion of bleeding or hematoma formation at the catheterization site. However, since the dressing is reported to be dry and intact, and the client is experiencing systemic symptoms, the priority is to assess for potential systemic complications first.

A. Walk frequently during recovery. B. Advance diet from clear liquids to full liquid. C. Anticipate weight loss will continue even with normal diet. D. Begin taking supplements per the healthcare provider's orders. E. Expect immediate return of ovulation. F. Start with room temperature water. G. Encourage three large meals a day.

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.

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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

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?

Correct Answer is A

Explanation

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

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