A nurse is monitoring a 14 year old adolescent who was admitted with a severe burn injury and shock and is receiving IV fluid resuscitation therapy. Assessment findings: Temperature 36.5C, HR 122, Respirations 22, BP 108/68. The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?
BP
Heart rate
Weight
Urine output
The Correct Answer is B
A. Blood pressure may fluctuate but is less sensitive as an early indicator of fluid resuscitation efficacy.
B. A decrease in heart rate is a sign of improved hydration status, as tachycardia is often a compensatory response to hypovolemia.
C. Weight is not used as an immediate indicator for fluid resuscitation adequacy.
D. Urine output should increase with adequate fluid resuscitation; a decrease in urine output would indicate worsening.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}
Explanation
Stevens-Johnson syndrome: This is a serious skin reaction that can be triggered by medications such as phenytoin. The child has reported itchy, hyperpigmented patches with scratch marks and dried blood, which raises concern for a drug-induced skin reaction.
Skin rash: The presence of a skin rash, particularly one that is itchy and may be associated with recent medication changes, warrants close monitoring for potential development of Stevens-Johnson syndrome.
Correct Answer is ["A","B","C","E"]
Explanation
A. Hypotension is common due to neurogenic shock in spinal cord injuries.
B. Hyperthermia can result from loss of autonomic control of temperature regulation.
C. A weakened gag reflex is possible with cervical spinal injuries, increasing the risk of aspiration.
D. Polyuria is not a common complication directly related to spinal cord injury.
E. Absence of bowel sounds can indicate paralytic ileus, a potential complication in spinal cord injuries.
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