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 D
Explanation
A. Sleep: While sleep is important for overall health, it is not as directly preventive of cardiac disease, falls, and depression as exercise.
B. Medications: Medications can manage symptoms but are not preventive measures for these conditions.
C. Nutrition: Nutrition is important for health but does not directly address the prevention of falls and depression as effectively as exercise.
D. Exercise: Regular exercise is known to improve cardiovascular health, reduce the risk of falls by improving strength and balance, and alleviate symptoms of depression through the release of endorphins and other benefits.
Correct Answer is C
Explanation
A. A resident with dementia who requires assistance eating: While this resident might have complications due to a weakened immune system, chemotherapy significantly increases the risk of complications from herpes zoster.
B. A resident who is sexually active: Sexual activity does not increase the risk of complications from herpes zoster.
C. A resident who is undergoing chemotherapy for breast cancer: Chemotherapy significantly compromises the immune system, making the resident more susceptible to severe complications from herpes zoster.
D. A resident recovering from a hip fracture: While recovering from a hip fracture is a stressor, it does not have as significant an impact on the immune system as chemotherapy.
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