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A nurse is monitoring a client who was admitted with a severe burn injury and is receiving IV fluid resuscitation therapy.

The nurse should identify a decrease in which of the following findings as an indication of adequate fluid replacement?

A.

Heart rate

B.

Blood pressure

C.

Weight

D.

Urine output

Answer and Explanation

The Correct Answer is A

Choice A rationale:
A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
Choice B rationale:
Blood pressure is not a reliable indicator of fluid volume status. It can be influenced by many factors, including pain, anxiety, and medications.
Choice C rationale:
Weight is not a reliable indicator of fluid volume status in the short term. It can take several days for changes in fluid volume to be reflected in weight.
Choice D rationale:
Urine output is a good indicator of kidney function, but it is not a reliable indicator of fluid volume status. Many factors can influence urine output, including kidney function, fluid intake, and medications.
 


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Related Questions

Correct Answer is A

Explanation

Choice A rationale:
Limiting dietary intake of salt prior to menses can help reduce fluid retention and breast swelling, thus minimizing discomfort.
Choice B rationale:
Taking tub baths doesn’t necessarily minimize discomfort associated with FBC. Hot water running over the breast tissue doesn’t have a significant impact on FBC symptoms.
Choice C rationale:
Removing the bra at night might provide some relief but it’s not a primary strategy for minimizing discomfort in FBC.
Choice D rationale:
Reducing fluid intake to 1 liter per day during menstruation is not recommended. Adequate hydration is important for overall health.

Correct Answer is C

Explanation

Choice A rationale:
Trimming the nails at the lateral corners can lead to ingrown toenails, which can cause pain and infection.
Choice B rationale:
Cleaning under the nail with an orange stick can cause injury to the nail bed and lead to infection.
Choice C rationale:
Filing the nails in a rounded shape can prevent injury and is the recommended method for nail care.
Choice D rationale:
Pushing the cuticles back with a metal nail file can cause injury and infection.

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