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. 12 or younger: While early onset is a risk factor, it is not as predictive as ages slightly older, where patterns of behaviour are more established.
B. 10 or younger: Very early onset is a risk factor but is less common and less studied.
C. 14 or younger: Research shows that starting alcohol consumption at 14 or younger significantly increases the risk of developing alcohol addiction.
D. 8 or younger: While extremely early onset is concerning, it is less predictive than slightly older ages due to the rarity and less data available.
Correct Answer is D
Explanation
A. Every 6 months. Semi-annual screenings may be necessary for certain conditions or if there are ongoing health issues, but generally, an annual check-up is sufficient for preventive health.
B. Every 3 years. This interval is too long for preventive health screenings in older adults, who are at higher risk for various health conditions.
C. Every 2 years. This interval may be appropriate for certain screenings, but annual check-ups are recommended to ensure timely detection and management of health issues.
D. Every year. Annual health screenings are recommended for older adults to monitor for chronic conditions, update vaccinations, and promote overall health.
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