A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Auscultate cuff blood pressure.

Monitor the pulmonary artery pressure.

Palpate pulse pressure.

Obtain a central venous pressure.

Answer and Explanation

The Correct Answer is B

A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.

B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.

C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.

D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.

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Correct Answer is B

Explanation

A. Obtaining a dietary history is relevant for ongoing management but is not the initial priority.

B. Reviewing electrolyte values is essential because exacerbations of ulcerative colitis can lead to severe fluid and electrolyte imbalances, which need prompt correction.

C. Investigating emotional concerns is important but does not take precedence over addressing potential electrolyte imbalances that can be life-threatening.

D. Checking perianal skin integrity is relevant for comfort but is not the priority in stabilizing the client during an acute exacerbation.

A. Urge incontinence B. Weight gain C. Rectal distention D. Dribbling of urine

Correct Answer is D

Explanation

A. Urge incontinence may occur but is not necessarily an indicator for immediate catheterization in a paraplegic patient, as they may lack bladder control.

B. Weight gain is unrelated to the need for catheterization and may indicate other issues like fluid retention.

C. Rectal distention relates to bowel function, not bladder function, and does not indicate the need for catheterization.

D. Dribbling of urine can suggest bladder overfilling and is an indication that the bladder needs emptying through catheterization to prevent urinary retention complications.

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A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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