A nurse is caring for a client who has full-thickness burns over 75 The nurse should use which of the following methods to monitor the cardiovascular system?
Monitor the pulmonary artery pressure.
Auscultate cuff blood pressure.
Obtain a central venous pressure.
Palpate pulse pressure.
The Correct Answer is C
Choice A rationale
Pulmonary artery pressure monitoring via a Swan Ganz catheter provides detailed information about left ventricular function and pulmonary vascular resistance. While useful in complex critical care cases, it is an invasive procedure with significant risks like dysrhythmias or pulmonary infarction. For a standard burn patient with 75 percent coverage, central venous pressure is usually the initial preferred method to guide the massive fluid resuscitation required during the first 24 to 48 hours.
Choice B rationale
Auscultating blood pressure using a cuff is often inaccurate or impossible in patients with 75 percent full thickness burns. The presence of significant edema, or the fact that the burns may cover all four extremities, prevents the effective use of a standard sphygmomanometer. Even if a site is available, the massive fluid shifts and decreased peripheral perfusion during burn shock make non invasive cuff pressures unreliable for guiding life saving titration.
Choice C rationale
Obtaining a central venous pressure is the most effective way to monitor fluid volume status in a severely burned patient. Full thickness burns over 75 percent of the body cause massive capillary leak and hypovolemia. CVP monitoring allows the healthcare team to assess the pressure in the right atrium and vena cava, providing a direct measurement of preload. This ensures that fluid resuscitation is sufficient to maintain organ perfusion without causing fluid overload.
Choice D rationale
Palpating pulse pressure provides a general sense of stroke volume and arterial tone, but it is purely subjective and lacks the precision needed for a patient in critical condition. In a patient with extensive burns, peripheral pulses may be difficult to palpate due to edema or eschar formation. Relying on manual palpation is insufficient for the minute to minute hemodynamic monitoring required to manage the complex fluid requirements of major burn injuries. .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["2.5"]
Explanation
Step 1 is 20 mg ÷ (40 mg ÷ 5 mL).
Step 2 is 20 mg ÷ 8 mg/mL.
Step 3 is 2.5 mL.
Correct Answer is D
Explanation
Choice A rationale
Donepezil is an acetylcholinesterase inhibitor that increases the concentration of acetylcholine in the gastrointestinal tract, which typically stimulates peristalsis and gastric acid secretion. Consequently, the most common gastrointestinal side effects are diarrhea, nausea, and vomiting rather than constipation. Monitoring for constipation would be inappropriate because the pharmacological action of the drug tends to promote bowel movements. Understanding this cholinergic effect helps caregivers manage the client's nutritional and hydration status effectively during drug therapy.
Choice B rationale
Donepezil increases parasympathetic nervous system activity by inhibiting the breakdown of acetylcholine. This cholinergic enhancement can affect the sinoatrial node of the heart, leading to bradycardia, which is a slow heart rate, rather than tachycardia. Tachycardia is not a common side effect of this medication. Patients with underlying cardiac conduction issues must be monitored closely for significant drops in heart rate or heart block, which could lead to decreased cardiac output and subsequent dizziness.
Choice C rationale
Donepezil is typically administered once daily in the evening, just before the client goes to sleep. Evening administration is recommended to minimize the impact of common side effects like nausea or dizziness that may occur shortly after taking the dose. Taking the medication at bedtime allows the peak plasma levels to occur while the patient is resting, potentially improving tolerance and adherence. Administering it in the morning might increase the risk of daytime gastrointestinal distress or lightheadedness.
Choice D rationale
Syncope, or fainting, can occur in clients taking donepezil due to the drug's vagotonic effects on the heart rate. By increasing acetylcholine levels, the medication can induce bradycardia or even temporary heart block, leading to a sudden drop in blood pressure and cerebral perfusion. Family members must be educated to monitor for signs of low heart rate or sudden dizziness, as these episodes increase the risk of falls and related injuries in elderly patients with Alzheimer's disease.
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