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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Encouraging brief exercise before meals to promote appetite is not directly related to feeding safety for a client who has dysphagia following a stroke.
Choice B rationale:
Placing the client with the head reclined back to facilitate swallowing is incorrect. It’s safer for the client to sit upright during feeding to prevent aspiration.
Choice C rationale:
Encouraging the client to take small bites can help prevent choking and aspiration, making it a safe feeding practice for clients with dysphagia.
Choice D rationale:
Placing food in the affected side of the mouth is not a safe practice. It’s recommended to place food on the unaffected side of the mouth.
Correct Answer is C
Explanation
Choice A rationale:
A thrombotic stroke occurs when a blood clot forms in one of the arteries that supply blood to the brain. It does not typically cause a sudden, severe headache and vomiting.
Choice B rationale:
A transient ischemic attack (TIA), or “mini-stroke,” is a temporary blockage of blood flow to the brain. It does not cause a sudden, severe headache and vomiting.
Choice C rationale:
A hemorrhagic stroke occurs when a blood vessel in the brain bursts, causing bleeding into the brain. This can cause a sudden, severe headache and vomiting.
Choice D rationale:
An embolic stroke occurs when a blood clot or other debris forms away from your brain — commonly in your heart — and is swept through your bloodstream to lodge in narrower brain arteries. This type of stroke does not typically cause a sudden, severe headache and vomiting.
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