In a burn unit, what critical sign indicates successful fluid resuscitation in a client with extensive burns?
Urine output of 30 to 50 mL per hour.
Heart rate greater than 120 beats per minute.
Increase in body weight by 5 percent.
Decreased peripheral pulses.
The Correct Answer is A
Choice A rationale
Maintaining a urine output of 30 to 50 mL per hour is the gold standard indicator that fluid resuscitation is effectively restoring organ perfusion. This volume suggests that the kidneys are receiving enough blood to maintain a normal glomerular filtration rate. In burn patients, adequate urine production confirms that the intravascular volume has been sufficiently replaced to overcome the massive fluid shifts and capillary leak syndrome that occur immediately following a significant thermal injury.
Choice B rationale
A heart rate greater than 120 beats per minute is usually an indicator of ongoing stress, pain, or hypovolemia rather than successful resuscitation. Tachycardia suggests that the heart is still working excessively hard to maintain cardiac output in the face of low blood volume. A successful resuscitation should ideally lead to a stabilization of the heart rate towards a more normal range, typically below 110 beats per minute, as the intravascular volume is restored and sympathetic drive decreases.
Choice C rationale
While some weight gain is expected during the acute phase of burn care due to the administration of large volumes of crystalloid fluids and subsequent edema, an increase of 5 percent is not a specific indicator of successful resuscitation. Excessive weight gain can actually signal fluid overload or third-spacing rather than effective intravascular volume replacement. The goal of resuscitation is to support vital organ function with the least amount of fluid necessary, avoiding complications like pulmonary edema.
Choice D rationale
Decreased peripheral pulses are a concerning sign that may indicate inadequate systemic perfusion or localized compartment syndrome due to circumferential burns and excessive edema. Successful fluid resuscitation should result in the maintenance or improvement of peripheral pulses, indicating that blood is reaching the distal extremities. If pulses are weakening, it suggests that the circulatory status is deteriorating or that fluid is accumulating in the interstitial spaces so severely that it is compressing the arterial flow.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Flaky skin, or desquamation, is a non-specific finding that can be seen in various conditions, including chronic dermatitis or simple xerosis. It represents the shedding of the outermost layer of the epidermis and does not effectively differentiate between the deep bacterial infection of cellulitis and the more superficial inflammatory reaction of dermatitis. While it indicates a disturbance in skin barrier function, it lacks the diagnostic specificity required to confirm the presence of an acute infectious process.
Choice B rationale
The presence of pustules is a significant clinical cue that often points toward an infectious etiology, such as folliculitis or localized cellulitis, rather than simple contact dermatitis. Pustules contain purulent exudate consisting of white blood cells and cellular debris, signaling a primary immune response to bacteria like Staphylococcus aureus. While some forms of dermatitis can become secondarily infected, finding pustules early in the assessment prompts the clinician to investigate bacterial invasion more thoroughly through cultures.
Choice C rationale
A sunburn appearance, characterized by diffuse erythema, can be seen in both cellulitis and various types of dermatitis, such as actinic or contact dermatitis. Because both conditions involve vasodilation and increased blood flow to the skin, redness alone is not a reliable differentiator. Cellulitis typically presents with more distinct warmth and spreading borders, but the visual similarity to a sunburn makes it a poor diagnostic marker for distinguishing between the two inflammatory states.
Choice D rationale
Dry patches are common in many dermatological conditions, particularly atopic dermatitis or eczema, where the skin barrier is chronically compromised. While they indicate altered tissue integrity, they do not specifically suggest the deep tissue inflammation and infection characteristic of cellulitis. Cellulitis is more often associated with taut, shiny, and swollen skin rather than dry, scaly patches. Therefore, observing dry patches is more helpful for identifying chronic skin conditions rather than diagnosing an acute infection.
Correct Answer is D
Explanation
Choice A rationale
Providing wound care is an essential component of burn management to prevent infection and promote healing, but it is not the first priority. During the initial resuscitation phase of a burn injury, systemic stability takes precedence over local wound treatment. Once the patient's airway, breathing, and circulation are stabilized, the nurse can then focus on debridement, topical antibiotics, and dressing applications. Addressing the wound first while the airway is compromised could lead to a fatal outcome.
Choice B rationale
Assessing the skin condition is part of the initial head-to-toe survey and helps determine the total body surface area burned using the Rule of Nines. However, this assessment is secondary to life-saving measures. While knowing the extent of the burn is crucial for calculating fluid resuscitation needs, it does not supersede the immediate need to ensure that the patient can breathe. Physiologic stability must be established before detailed mapping of the cutaneous injuries is performed by the team.
Choice C rationale
Initiating nutritional support is a critical long-term intervention for burn patients because they enter a hypermetabolic state that requires significant caloric and protein intake for tissue repair. However, nutritional needs are addressed in the days following the injury, not in the first minutes or hours. Immediate life-threats must be managed before metabolic demands are considered. Providing high-protein and high-calorie nutrition is vital for recovery, but it is not the highest priority during the acute emergency.
Choice D rationale
Ensuring a patent airway is the absolute first priority in the care of a patient with burn injuries, particularly if there is a risk of inhalation injury. Thermal or chemical burns can cause rapid edema of the upper airway, leading to total obstruction and respiratory failure. In any emergency situation, the ABC sequence dictates that the airway must be secured first. Without a functional airway, all other interventions, including fluid resuscitation and wound care, will be ineffective in saving the patient.
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