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.

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Correct Answer is C

Explanation

A. Sinus Bradycardia: Sinus bradycardia is characterized by a heart rate below 60 beats per minute, which is clearly not the case in this EKG strip. The observed rate of 150 bpm is well above the bradycardic range.

B. Sinus Tachycardia: Although this is a fast rhythm (over 100 bpm), sinus tachycardia typically has visible and upright P waves preceding each QRS complex. In this strip, the P waves are not clearly visible, suggesting a non-sinus origin.

C. Supraventricular Tachycardia (SVT): SVT is a rapid, regular rhythm originating above the ventricles, often with no clearly identifiable P waves and narrow QRS complexes. The rate appears very fast and regular—typical of SVT.

D. Normal Sinus Rhythm (NSR): Normal sinus rhythm is characterized by a regular heart rate between 60 and 100 beats per minute, with normal P waves preceding each QRS. The heart rate of 150 bpm in the given strip falls outside the normal range for NSR.

A. A 30-year-old distraught mother holding her crying child B. A 65-year-old conscious male with a head laceration C. A 48-year-old with a simple fracture of the lower leg D. A 26-year-old male who has pale, cool, clammy skin

Correct Answer is D

Explanation

A. A 30-year-old distraught mother holding her crying child: While the mother is distraught, her condition does not appear life-threatening. This client should be triaged to a lower priority compared to those with immediate medical needs.

B. A 65-year-old conscious male with a head laceration: A head laceration in a conscious client is concerning but not immediately life-threatening unless there are signs of more serious brain injury (e.g increased intracranial pressure). This client would be triaged as urgent, not emergent.

C. A 48-year-old with a simple fracture of the lower leg: A simple fracture is painful but does not typically threaten life or limb. This client is categorized as urgent but not emergent compared to others with more critical needs.

D. A 26-year-old male who has pale, cool, clammy skin: This client is showing signs of shock, which is a medical emergency. Pale, cool, and clammy skin suggests hypoperfusion, potentially due to hemorrhage, dehydration, or trauma. This client requires immediate intervention to restore circulation and prevent further deterioration.

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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 C

Explanation

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

Correct Answer is D

Explanation

A nurse is caring for a client who has symptomatic sinus bradycardia. The Atropine was given but was not successful. Which one of the following is the next intervention?

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

A nurse is caring for a client who has atrial fibrillation and is receiving heparin. Which of the following findings is the nurse's priority?

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nursing priority?

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client?

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