A nurse is caring for a school-age child who has full-thickness burns to 30% of the total body surface area (TBSA). The nurse is initiating the client's plan of care. Complete the following sentence by using the list of options.
The client is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Choice A reason: Hypovolemia is a condition of low blood volume due to fluid loss from the burn injury. It can cause decreased urine output, hypotension, tachycardia, and poor skin turgor. The nurse should monitor the client's vital signs, fluid intake and output, and weight. The nurse should administer lactated Ringer's solution to maintain urine output of 30 ml/hr.
Choice B reason: Hyperkalemia is a condition of high potassium levels in the blood due to cellular damage from the burn injury. It can cause peaked T waves, dysrhythmias, muscle weakness, and cardiac arrest. The nurse should monitor the client's serum potassium levels, electrocardiogram, and cardiac status. The nurse should avoid administering potassium-containing fluids or medications.
Choice C reason: Hypocalcemia is a condition of low calcium levels in the blood due to fluid shifts from the burn injury. It can cause positive Chvostek's sign, tetany, seizures, and hypotension. The nurse should monitor the client's serum calcium levels, neurological status, and blood pressure. The nurse should administer calcium supplements as prescribed.
Choice D reason: Hypernatremia is a condition of high sodium levels in the blood due to fluid loss from the burn injury. It can cause dry mucous membranes, thirst, agitation, and seizures. The nurse should monitor the client's serum sodium levels, hydration status, and mental status. The nurse should administer hypotonic fluids as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Choice A reason: Gingival hyperplasia is a condition where the gums become enlarged and inflamed. It is a common side effect of Phenytoin, a medication used to treat seizures. The nurse should educate the client and the guardian about the importance of oral hygiene and regular dental check-ups to prevent or manage this condition.
Choice B reason: Hypoglycemia is a condition where the blood glucose level becomes too low. It is not a common side effect of albuterol, a medication used to treat asthma. Albuterol may cause tremors, tachycardia, or nervousness, but not hypoglycemia.
Choice C reason: Status epilepticus is a condition where seizures occur repeatedly without recovery. It is a medical emergency that requires immediate treatment. It may be triggered by exercise, but not necessarily. The nurse should ensure that the client has their seizure medication and rescue inhaler available at all times and knows how to use them.
Choice D reason: Bronchospasm is a condition where the airways become narrowed and obstructed. It is a common symptom of asthma, but not a side effect of Phenytoin. Phenytoin may cause other adverse effects, such as rash, nausea, or drowsiness, but not bronchospasm.
Correct Answer is D
Explanation
Choice A reason: This is not a correct description of Bryant traction. This type of traction does not involve pins or wires inserted into the bone. It is a skin traction that uses adhesive straps or bandages attached to the skin of the lower legs.
Choice B reason: This is not a correct description of Bryant traction. This type of traction does not maintain the leg in an extended position. It flexes the hip and knee at a 90-degree angle and suspends the leg in the air.
Choice C reason: This is not a correct description of Bryant traction. This type of traction does not use a sling under the knee of the affected leg. It uses a spreader bar to keep the legs apart and prevent rotation.
Choice D reason: This is a correct description of Bryant traction. This type of traction elevates the buttocks slightly off of the bed to provide countertraction and alignment of the fractured bone.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today