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?

Heart rate

Blood pressure

Weight

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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Correct Answer is D

Explanation

Choice A rationale:
Administering pain medication is important, but it’s not the first priority. The first priority is to stabilize the client’s condition.
Choice B rationale:
Administering a tetanus booster is necessary for burn patients, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice C rationale:
Cleaning and dressing the wound is important, but it’s not the first intervention. The first intervention should be to stabilize the client’s condition.
Choice D rationale:
Administering IV fluids is the first intervention for a burn patient. This is because burns can cause significant fluid loss, leading to dehydration and shock.

A. "Limit your dietary intake of salt prior to menses.”. B. "Take tub baths to avoid hot water running over your breast tissue.”. C. "Remove your bra at night while sleeping.”. D. "Reduce your fluid intake to 1 liter per day during menstruation.”.

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.

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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?

Nursing Test Bank

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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?