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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3300"]
Explanation
Calculation:
- Calculate the total volume from the continuous IV infusion over 24 hours.
Continuous infusion rate = 125 mL/hr
Time = 24 hr
Volume from continuous infusion = 125 mL/hr × 24 hr
= 3000 mL.
- Calculate the total volume from the cefazolin IV bolus over 24 hours.
Cefazolin bolus volume per dose = 50 mL
Frequency = every 4 hr
Number of doses in 24 hr = 24 hr / 4 hr/dose
= 6 doses.
Volume from cefazolin bolus = 50 mL/dose × 6 doses
= 300 mL.
- Calculate the total IV fluid intake over 24 hours.
Total IV fluid intake = Volume from continuous infusion + Volume from cefazolin bolus
= 3000 mL + 300 mL
= 3300 mL.
Correct Answer is ["A","C","D"]
Explanation
Rationale:
A. Chronic Kidney Disease (CKD): The elevated BUN and creatinine levels, along with the client's decreased urine output and fluid retention, suggest impaired kidney function, increasing the risk for chronic kidney disease, especially with underlying comorbidities.
B. Hyperglycemia: There are no signs or symptoms indicating hyperglycemia, so hyperglycemia is unlikely to be a concern in this case based on the presented findings.
C. Uremia: Uremia occurs when waste products accumulate in the blood due to renal dysfunction, and the elevated BUN and creatinine, combined with symptoms like fatigue and dyspnea, indicate this condition in the client.
D. Hyperkalemia: Impaired kidney function limits potassium excretion, increasing the risk for hyperkalemia. Given the client’s kidney impairment, this can lead to elevated potassium levels and potentially cause life-threatening arrhythmias.
E. Polycystic Kidney Disease: Polycystic kidney disease typically presents with a gradual onset of symptoms like kidney enlargement and a family history, which the client’s acute presentation does not support, making PKD an unlikely diagnosis.
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