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?

Bilateral lung crackles

1+ pitting peripheral edema

Engorged neck veins

Urine output 25 mL/hr

Answer and Explanation

The Correct Answer is D

Rationale:

A. Bilateral lung crackles: Bilateral lung crackles are typically a sign of fluid overload or pulmonary edema, not fluid loss. They do not indicate the need for fluid resuscitation in the case of burns.

B. 1+ pitting peripheral edema:1+ pitting edema is mild and does not typically indicate the need for fluid resuscitation. It may occur with minor fluid retention, but it is not a severe indication of dehydration or fluid loss that would require resuscitation.

C. Engorged neck veins: Engorged neck veins suggest fluid overload or venous congestion, often seen in conditions like heart failure, but not in the immediate need for fluid resuscitation for burn patients.

D. Urine output 25 mL/hr: A urine output of 25 mL/hr is below the normal range (30 mL/hr or more) and suggests inadequate renal perfusion. This is a clear indicator that the client may require fluid resuscitation to restore adequate circulation and kidney function.

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Correct Answer is B

Explanation

Rationale:

A. "Drink a glass of milk with each meal." While milk can be a good source of calcium and protein, it may increase mucus production, which can be uncomfortable for clients with COPD or increase the work of breathing.

B. "Plan to include high-protein foods in each of your meals. "High-protein foods are essential for clients with COPD, as they help maintain muscle mass, support immune function, and prevent weight loss. These benefits are important for COPD patients, who may experience increased energy expenditure due to labored breathing.

C. "Increase your intake of vegetables such as broccoli and brussels sprouts." While vegetables are important, certain cruciferous vegetables like broccoli and brussels sprouts can cause gas and bloating, which can lead to discomfort for clients with COPD.

D. "Consume three large meals throughout the day." Clients with COPD may have difficulty consuming large meals due to breathlessness or early satiety. It is better to recommend smaller, more frequent meals to ensure adequate caloric intake.

A. Client urinating 100 mL/hour. B. Client is tolerating soft diet and oral fluids. C. Bowel sounds are hyperactive in all 4 quadrants. D. Bilateral pedal pulses 2+. E. Blood glucose 310 mg/dL (74 to 106 mg/dL) F. Pulse rate 84/min G. Blood pressure 106/76 mm Hg

Correct Answer is ["A","B","D","E","F","G"]

Explanation

Rationale for correct findings:

Client is urinating 100 mL/hour: This indicates improved kidney perfusion and rehydration. At 0900, the client reported frequent urination, which was likely osmotic diuresis leading to dehydration. A consistent urine output of 100 mL/hour suggests effective fluid resuscitation and that the kidneys are now functioning more optimally.
Client is tolerating soft diet and oral fluids: The ability to tolerate a soft diet and oral fluids suggests that the client is recovering from nausea and dehydration. This is an important indicator of improvement in gastrointestinal function and overall metabolic status.
Pulse rate decreased to 84/min: The pulse rate has decreased from 110/min to 84/min, indicating that the client’s cardiovascular status is improving, likely due to improved hydration and metabolic control.
Blood pressure increased to 106/76 mm Hg: The client’s blood pressure has improved from 96/65 mm Hg to 106/76 mm Hg, reflecting a more stable circulatory volume and better perfusion. This improvement suggests that fluid resuscitation is helping to stabilize the client’s hemodynamic status.
Blood glucose decreased to 310 mg/dL: A decrease in blood glucose from 468 mg/dL to 310 mg/dL shows that insulin therapy is having a positive effect on reducing hyperglycemia. The blood glucose level is still high but moving in the right direction, indicating recovery from the acute phase of hyperglycemia.

Rationale for Incorrect Finding:

Bowel sounds are hyperactive in all 4 quadrants: Hyperactive bowel sounds remain unchanged from the initial assessment. It is not a sign of improvement, and could be related to the stress response, medications, or ongoing issues with the gastrointestinal system.

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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?

Nursing Test Bank

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Explanation

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Explanation

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