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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The client was last suctioned 6 hours ago: Time alone doesn’t indicate the need for suctioning. Suctioning is performed based on assessment findings, not routine schedules.
B. The client's respiratory rate is 32 breaths/min: A rapid respiratory rate can signal airway obstruction, secretions, or respiratory distress—all of which may require suctioning to improve ventilation.
C. The client has occasional audible expiratory wheezes: Wheezes suggest lower airway narrowing, which typically doesn’t improve with suctioning. Suctioning targets upper airway secretions, not bronchospasm.
D. The client's oxygen saturation drops to 95%: A saturation of 95% is still within normal limits and doesn't, by itself, suggest the need for suctioning unless accompanied by other signs like crackles, visible secretions, or distress.
Correct Answer is ["0.8"]
Explanation
Desired dose = 3,800 units.
Available concentration = 5,000 units/mL.
- Calculate the volume to administer.
Volume (mL) = Desired dose (units) / Available concentration (units/mL)
= 3,800 units / 5,000 units/mL
= 0.76 mL.
- Round the answer to the nearest tenth.
= 0.8 mL.
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