A nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

"When the antibiotic therapy is complete."

"As soon as his albumin levels return to normal."

"Once we complete the fluid resuscitation process."

"When all of his burn wounds have closed."

Answer and Explanation

The Correct Answer is D

Choice A reason: Completion of antibiotic therapy does not necessarily correlate with a decrease in the risk of infection in burn patients. While antibiotics can help manage existing infections, the risk for new infections remains until the burn wounds are fully healed. Open burn wounds provide a portal of entry for pathogens, and the presence of necrotic tissue can further increase infection risk.

Choice B reason: Returning albumin levels to normal can improve the overall nutritional status and healing process of a burn patient, but it does not directly reduce the risk of infection. Albumin levels are more indicative of the patient's nutritional status and fluid balance. The primary concern for infection risk remains the open burn wounds, which serve as a direct route for pathogens.

Choice C reason: Completion of the fluid resuscitation process is crucial for stabilizing a burn patient's hemodynamic status and ensuring adequate perfusion to tissues. However, fluid resuscitation does not directly impact the risk of infection. The risk of infection is predominantly related to the presence and extent of open burn wounds.

Choice D reason: The correct response is that the risk for infection significantly decreases when all of the burn wounds have closed. Closed wounds provide a barrier against pathogens and reduce the risk of infection. Wound closure can be achieved through natural healing or surgical interventions such as skin grafting. Until the wounds are fully closed, the patient remains at a high risk for infection.

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 A

Explanation

Choice A reason: Decerebrate posturing is characterized by the extension of the arms and legs, pronation of the arms, and plantar flexion. This type of posturing indicates severe brain damage, typically involving the brainstem. It is a sign of a more serious injury than decorticate posturing and suggests that the damage has progressed to affect the brainstem.

Choice B reason: Flexion withdrawal is a response to a painful stimulus where the patient pulls away from the pain. It is a reflex that indicates some level of preserved spinal cord or brainstem function. However, it does not involve the specific pattern of extension and pronation seen in decerebrate posturing.

Choice C reason: Decorticate posturing involves flexion of the arms, clenched fists, and extension of the legs. The arms are bent inward toward the body with the wrists and fingers flexed on the chest. This posturing indicates damage to the brain's cortical areas or the corticospinal tract. It is less severe than decerebrate posturing.

Choice D reason: Localization of pain is a response where the patient moves a hand towards the site of the painful stimulus, indicating a higher level of brain function. This response suggests that the brain can still process and respond to the location of the pain, which is not consistent with the described posturing.

A. Administering normal saline 500-1000 mL infused over 1 hour. B. Administering drugs to suppress aldosterone release. C. Having the patient drink several large glasses of water. D. Instilling 500-1000 mL of normal saline through a nasogastric tube.

Correct Answer is A

Explanation

Choice A reason: Administering normal saline 500-1000 mL infused over 1 hour is an effective fluid challenge to promote kidney perfusion in patients with acute kidney injury and no signs of fluid overload. This intervention helps increase intravascular volume, improving renal blood flow and potentially enhancing urine output.

Choice B reason: Administering drugs to suppress aldosterone release is not appropriate for promoting kidney perfusion in this context. Suppressing aldosterone could potentially decrease sodium and water reabsorption, which may not be beneficial for improving renal perfusion in a patient with acute kidney injury.

Choice C reason: Having the patient drink several large glasses of water is not the most effective method for a fluid challenge. Oral intake may not provide the rapid volume expansion needed to improve kidney perfusion, especially in a patient with acute kidney injury where fluid balance and perfusion are critical.

Choice D reason: Instilling 500-1000 mL of normal saline through a nasogastric tube is not an appropriate fluid challenge for promoting kidney perfusion. This method is not typically used for volume expansion in the context of acute kidney injury, as it may not provide the rapid intravascular volume increase needed to enhance renal blood flow.

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 nurse cares for a patient who has burn injuries. The patient's wife asks, "When will his high risk for infection decrease?" How would the nurse respond?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with the extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Correct Answer is A

Explanation

A nurse is caring for a postoperative 70-kg patient who had major blood loss during surgery and now has acute kidney injury. The patient does not have signs of fluid overload. Which intervention would be most effective as a fluid challenge to promote kidney perfusion?

Correct Answer is A

Explanation

To determine treatment effectiveness in a patient with pancreatitis, the nurse should monitor which of these tests?

A patient with late-stage cirrhosis develops portal hypertension. All of the following are potential complications that can develop from this condition. Select all that apply.

When providing care for a client hospitalized with acute pancreatitis who has acute abdominal pain, which nursing interventions would be most appropriate for this client? Select all that apply.

To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position?

The healthcare provider recommends to a patient that diagnostic testing be performed to assess for valvular heart disease. The nurse teaches the patient about which test that is commonly used to assess the valves?

The nurse is caring for a client who is receiving the ACE inhibitor lisinopril. Which of the following outcomes should the nurse anticipate?

The nurse is caring for a newly admitted patient with sepsis and has received orders from the physician. What order should the nurse implement first?