A nurse is caring for a patient with 40% TBSA burns who is receiving fluid resuscitation. Which of the following nursing interventions is the priority?

Weigh the patient daily to monitor fluid balance.

Monitor urine output to ensure at least 30 mL/hr.

Assess for signs of fluid deficit such as lung crackles and engorged neck veins.

Administer only colloid solutions within the first 8 hours post-burn.

Answer and Explanation

The Correct Answer is B

A. Weigh the patient daily to monitor fluid balance. Daily weights are useful for tracking fluid shifts but are not the priority in the acute phase of burn management.

B. Monitor urine output to ensure at least 30 mL/hr. Urine output is a key indicator of adequate fluid resuscitation. A minimum of 30 mL/hr ensures proper kidney perfusion and prevents hypovolemia or fluid overload.

C. Assess for signs of fluid deficit such as lung crackles and engorged neck veins. Crackles and neck vein distension indicate fluid overload, not deficit. While monitoring for overload is important, urine output is the best immediate indicator of effective fluid resuscitation.

D. Administer only colloid solutions within the first 8 hours post-burn. Crystalloids (e.g., Lactated Ringer’s) are the primary fluids used in the first 24 hours post-burn. Colloids are typically introduced later.

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Correct Answer is A

Explanation

A. Impetigo. Impetigo is a highly contagious bacterial skin infection, often caused by Staphylococcus aureus or Streptococcus pyogenes. It is characterized by honey-colored crusted lesions, especially around the mouth and extremities.

B. Scabies. Scabies presents as intensely itchy burrows or papules, often in the web spaces of the fingers, wrists, and axillae, rather than honey-colored crusts.

C. Herpes simplex virus. Herpes simplex virus (HSV) typically causes grouped vesicular lesions on an erythematous base, not crusted honey-colored lesions.

D. Tinea corporis. Tinea corporis (ringworm) presents as red, scaly, annular lesions with central clearing, not honey-colored crusts.

A. Increased hip range of motion and absence of pain B. Reports of hearing a "pop" at the time of pain onset C. Ability to bear weight on the affected leg without discomfort D. Symmetric leg length with normal alignment

Correct Answer is B

Explanation

A. Increased hip range of motion and absence of pain. A hip dislocation causes severe pain and reduced mobility, not increased range of motion. This option is incorrect.

B. Reports of hearing a "pop" at the time of pain onset. A "popping" sound often occurs when the prosthetic hip dislocates from the joint, making this a key symptom of hip dislocation.

C. Ability to bear weight on the affected leg without discomfort. A hip dislocation causes severe pain and functional impairment, making weight-bearing extremely difficult or impossible.

D. Symmetric leg length with normal alignment. A dislocated hip causes the affected leg to appear shortened and externally rotated, so symmetrical leg length would not be expected.

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A nurse is caring for a patient with 40% TBSA burns who is receiving fluid resuscitation. Which of the following nursing interventions is the priority?

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