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 A
Explanation
A. Obsessive-compulsive: This behavior involves persistent, intrusive thoughts (obsessions) and repetitive behaviors (compulsions) aimed at reducing anxiety, fitting the definition of obsessive-compulsive disorder.
B. Anxiety tension: Anxiety tension is a broader term and does not specifically address the repetitive checking behavior seen in obsessive-compulsive disorder.
C. Controlled repetition: This term is not commonly used to describe a specific psychological condition related to repeated behaviors due to obsessive thoughts.
D. Senseless behavior: The behavior is not senseless but is driven by anxiety and obsessive-compulsive tendencies.
Correct Answer is D
Explanation
A. Orlaam is used for maintenance therapy in opioid dependence, not for acute overdose reversal.
B. Clonidine is used to manage withdrawal symptoms but does not reverse opioid overdose.
C. Methadone is used for maintenance therapy and withdrawal management but does not reverse an overdose.
D. Narcan (naloxone) is the drug of choice to reverse the effects of opioid overdose by displacing opioids from receptor sites.
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