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 B
Explanation
A. Heart attacks due to increased effort to ambulate: While heart attacks are a concern, they are not directly related to musculoskeletal changes and posture.
B. Falls related to posture changes: Age-related changes such as decreased muscle mass and changes in posture increase the risk of falls.
C. Fractures due to poor uptake of calcium: While decreased calcium absorption can lead to fractures, age-related musculoskeletal changes like posture and muscle weakness are more directly linked to fall risk.
D. Respiratory failure due to kyphosis: Kyphosis can impact respiratory function, but the most direct risk from musculoskeletal changes in older adults is falls.
Correct Answer is A
Explanation
A. Mood disorders: Mood disorders, such as bipolar disorder and major depressive disorder, involve severe and persistent disturbances in mood and emotions.
B. Anxiety disorders: Anxiety disorders involve excessive fear or anxiety, not primarily mood disturbances.
C. Thought process disorders: Thought process disorders, such as schizophrenia, involve disordered thinking but are not primarily characterized by mood disturbances.
D. Personality disorders: Personality disorders involve enduring patterns of behavior and thought that deviate from cultural expectations, not necessarily involving severe mood disturbances
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