A nurse is assessing the fluid status of a patient who sustained 40% second degree burns to chest and extremities. The client is 5 hours post-burn injury. The nurse determines that the client is exhibiting signs of inadequate fluid volume and notifies the physician because the client is exhibiting the following:

Pulse rate 108 bpm and temperature 99.2F

Resp rate 18 and pulse rate 78 bpm

B/P 109/65 and pulse rate 90 bpm

Pulse rate 138 bpm and urine output 22mL/hr

Answer and Explanation

The Correct Answer is D

A. Pulse rate 108 bpm and temperature 99.2F: A pulse rate of 108 bpm is elevated, but it is within the normal compensatory range for a burn injury. A temperature of 99.2°F is slightly elevated, which may be expected after a burn injury due to stress or inflammation.

B. Resp rate 18 and pulse rate 78 bpm: A pulse rate of 78 bpm is normal, and a respiratory rate of 18 breaths per minute is within the normal range. These findings suggest that the client's fluid status is stable and does not indicate signs of inadequate fluid volume.

C. B/P 109/65 and pulse rate 90 bpm: A blood pressure of 109/65 mm Hg is within normal limits, and a pulse rate of 90 bpm is slightly elevated but within a normal compensatory range. These do not indicate significant fluid deficit at this time.

D. Pulse rate 138 bpm and urine output 22mL/hr: A pulse rate of 138 bpm is high and indicates tachycardia, which is a common compensatory mechanism due to inadequate fluid volume. The urine output of 22 mL/hr is below the expected output of 30 mL/hr, indicating poor renal perfusion and inadequate fluid status.

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

A. Asystole: Asystole is defined as the complete absence of electrical and mechanical cardiac activity. The EKG strip displays a flatline, indicating no ventricular depolarization or contraction, which is the hallmark of asystole. This rhythm is a non-shockable cardiac arrest rhythm.

B. Sinus Tachycardia: Sinus tachycardia is a regular rhythm with a heart rate greater than 100 bpm, characterized by clear P waves and QRS complexes. This is clearly not present in the given flatline strip.

C. Sinus Bradycardia: Sinus bradycardia is a regular rhythm with a heart rate less than 60 bpm, characterized by clear P waves and QRS complexes.

D. Supraventricular Tachycardia (SVT): SVT is a rapid rhythm, typically 150-250 bpm, with narrow QRS complexes and often obscured P waves.

A. Decrease chest wall compliance B. Induce sedation C. Decrease respiratory secretions D. Suppress respiratory effort

Correct Answer is B

Explanation

A. Decrease chest wall compliance: Chest wall compliance refers to the ability of the chest to expand and contract, and fentanyl does not directly affect this function. ARDS typically causes decreased compliance, but the medication’s primary role is not to address this issue.

B. Induce sedation: Fentanyl is a potent opioid analgesic that is used for its sedative and analgesic properties in clients who are mechanically ventilated. It helps to manage pain and anxiety, making the patient more comfortable and often necessary to facilitate ventilation and reduce discomfort.

C. Decrease respiratory secretions: Fentanyl does not primarily act to decrease respiratory secretions. Medications like anticholinergics (e.g., atropine) are used to decrease secretions, not opioids like fentanyl.

D. Suppress respiratory effort: While fentanyl may help reduce respiratory effort indirectly by providing sedation and pain relief, its primary purpose in this scenario is not to suppress respiratory effort. Its purpose is to manage pain and provide sedation, not control respiratory drive.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You note the cardiac electrical rhythm below (see 6-second EKG strip). Which of the following would BEST describe the client's rhythm?

Correct Answer is A

Explanation

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives an order for fentanyl. The nurse recognizes that this medication is for which of the following purposes?

Correct Answer is B

Explanation

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the client's caregiver is accurate?

A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?

A nurse is caring for a client who has burns to his face, ears, and eyelids. The nurse should identify which of the following is the priority finding to report to the provider?

A nurse in an emergency department is preparing to care for a client who is being brought in with multiple system trauma following a motor vehicle crash. Which of the following should the nurse identify as the priority focus of care?

An emergency room nurse is triaging victims of a mass-casualty event. Which client should receive care first?

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which two of the following findings should the nurse identify as a late sign of ICP? (Select all that apply)