The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
Monitor for signs of seizure activity.
Increase the IV rate and monitor for burn shock.
Raise the foot of the bed and apply blankets.
Assess for signs of fluid overload.
The Correct Answer is D
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Osteomyelitis: Osteomyelitis is an infection of the bone and does not directly impact the skeletal changes affecting lung function.
B. Osteoporosis: While osteoporosis affects bone density and may cause fractures, it is not specifically linked to changes in lung function related to skeletal changes.
C. Kyphosis: Kyphosis, or excessive curvature of the thoracic spine, can compress the thoracic cavity and reduce lung expansion, which impacts effective air exchange in COPD patients.
D. Arthritis: Arthritis affects joint function but does not have a direct impact on the skeletal changes that alter lung function like kyphosis does.
Correct Answer is C
Explanation
A. Rye bread is not a significant source of calcium.
B. Apples are not a significant source of calcium.
C. Yogurt often contains live cultures that can help with lactose digestion, and it is a good source of calcium. Its often tolerated by individuals with lactose intolerance.
D. Raisins have some calcium but are not sufficient to fulfil daily calcium needs compared to dairy alternatives.
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