On admission to the burn unit, a client with an appropriate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 59%, Hgb 19.2 mg/dL, Serum K 5.0 mEq/L and serum Na 150 mEq/L. Which action will the nurse anticipate taking now?

Type and crossmatch for a blood transfusion.

Increase the rate of IV Lactated Ringers solution per doctors order.

Continue to monitor the laboratory results.

Monitor Urine output every 8 hours.

Answer and Explanation

The Correct Answer is B

A. Type and crossmatch for a blood transfusion: The elevated hemoglobin and hematocrit reflect hemoconcentration due to fluid loss from the burn, not blood loss requiring transfusion. Immediate transfusion is not indicated at this stage.

B. Increase the rate of IV Lactated Ringers solution per doctor's order: High hematocrit, hemoglobin, and sodium indicate significant fluid deficit and dehydration from burn-related plasma loss. Rapid fluid resuscitation with isotonic crystalloids like Lactated Ringers is necessary to restore circulating volume, maintain perfusion, and prevent shock.

C. Continue to monitor the laboratory results: Ongoing monitoring is important, but active intervention with fluid resuscitation is required immediately to address hypovolemia. Passive monitoring alone would delay critical treatment.

D. Monitor urine output every 8 hours: Frequent urine output monitoring is essential in burn patients, but the standard is usually every 1 hour during the initial resuscitation phase. Waiting 8 hours is inadequate to detect early signs of hypoperfusion or renal compromise.

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Correct Answer is D

Explanation

A. Lower the head of the client’s bed in Trendelenburg position: Placing the client in Trendelenburg can increase venous return and worsen pulmonary congestion in someone with elevated CVP and PAWP, making this unsafe.

B. Document CVP and continue to monitor: While ongoing monitoring is important, it does not address the client’s acute fluid overload and heart failure exacerbation. Immediate intervention is needed.

C. Increase IV fluid infusion per protocol: The client already shows signs of volume overload (CVP 18 mmHg, PAWP 21 mmHg, low ejection fraction, and high BNP). Increasing fluids would exacerbate pulmonary congestion and worsen hypoxia.

D. Administer IV diuretic medication: The client’s elevated CVP, PAWP, and BNP, along with low SpO₂ and signs of fluid overload, indicate acute decompensated heart failure. Administering a diuretic is the priority to reduce preload, relieve pulmonary congestion, and improve oxygenation.

A. Encourage visitors in the early evening, B. Keep the client on fall risk precautions until discharge. C. Check on the client once a shift. D. Place all four side rails in the “up” position.

Correct Answer is B

Explanation

A. Encourage visitors in the early evening: While social support is beneficial, encouraging visitors does not directly prevent falls and may even contribute to confusion or distraction if the client is unstable.

B. Keep the client on fall risk precautions until discharge: Maintaining fall precautions consistently throughout the hospital stay helps prevent falls, especially in clients at high risk. This includes measures such as using non-slip footwear, keeping the call light within reach, and ongoing supervision.

C. Check on the client once a shift: Checking only once per shift is insufficient to prevent falls. Frequent monitoring and timely assistance with mobility are essential for fall prevention.

D. Place all four side rails in the “up” position: Raising all side rails can increase the risk of injury if the client attempts to climb over them and is not considered a safe fall prevention practice for adults.

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On admission to the burn unit, a client with an appropriate 25% total body surface area (TBSA) burn has the following initial laboratory results: Hct 59%, Hgb 19.2 mg/dL, Serum K 5.0 mEq/L and serum Na 150 mEq/L. Which action will the nurse anticipate taking now?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

A client is admitted and is placed on fall precautions. The nurse teaches the client and family about fall precautions. Which action will the nurse take to promote client safely?

Correct Answer is B

Explanation

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A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as “George Smith”. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?