A nurse is assessing a client who has full-thickness burns. The nurse should identify that which of the following findings indicates the client's need for fluid resuscitation?
Urine output 25 mL/hr
Engorged neck veins
1+pitting peripheral edema
Bilateral lung crackles
The Correct Answer is A
A. Urine output 25 mL/hr: Low urine output indicates inadequate renal perfusion, which can result from fluid loss due to burn injuries. In clients with full-thickness burns, maintaining adequate urine output is a key indicator that fluid resuscitation is needed to restore circulating volume and prevent shock.
B. Engorged neck veins: Engorged neck veins suggest fluid overload or increased central venous pressure rather than hypovolemia. This finding would not indicate the need for fluid resuscitation in a burn patient.
C. 1+ pitting peripheral edema: Mild peripheral edema may occur with fluid shifts but does not alone indicate the need for aggressive fluid resuscitation. It is less critical than indicators of organ perfusion such as urine output.
D. Bilateral lung crackles: Lung crackles indicate fluid accumulation in the lungs, possibly from pulmonary edema, and would suggest caution with fluid administration rather than the need for additional fluids.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Abdominal cramping: Mild abdominal cramping is common after a colonoscopy due to air insufflation during the procedure. This symptom is typically transient and not indicative of a serious complication.
B. Light-headedness: Light-headedness may indicate bleeding, hypotension, or hypovolemia, which are potential complications following a colonoscopy. This symptom requires prompt assessment to rule out internal bleeding or other serious adverse events.
C. Increased flatus: Passing gas is expected after colonoscopy because of residual air introduced during the procedure. This finding is a normal part of recovery and does not signal a complication.
D. Feeling of fullness: A sensation of fullness is common post-procedure and usually results from retained air or mild distention. It typically resolves spontaneously and is not considered a complication.
Correct Answer is D
Explanation
A. "You can cross your legs at the ankles when sitting down.": Crossing legs, even at the ankles, can increase the risk of hip dislocation following total hip arthroplasty. Clients should avoid crossing legs to maintain proper joint alignment and prevent complications.
B. "Clean the incision daily with hydrogen peroxide.": Hydrogen peroxide can damage healing tissue and delay wound healing. The incision should be cleaned gently with mild soap and water or as instructed by the surgeon to prevent infection without harming tissue.
C. "You should use an incentive spirometer every 8 hours.": Incentive spirometry is typically recommended more frequently, usually 10 times per hour while awake, to prevent postoperative pulmonary complications. Every 8 hours would be insufficient for effective lung expansion.
D. "Install a raised toilet seat in your bathroom.": A raised toilet seat helps the client maintain hip precautions by reducing hip flexion beyond 90 degrees, decreasing the risk of dislocation. This is an important safety modification for home care following hip arthroplasty.
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