The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

Urine output of 0.5-1 mL/kg/hr

Serum sodium level 149 mEq/L. (normal 135-145)

Blood pressure 82/54

Heart rate 124 beats per minute

Answer and Explanation

The Correct Answer is A

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

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Correct Answer is D

Explanation

A) Measure heart chamber pressures to assess for heart failure:
Measuring heart chamber pressures is an important diagnostic tool in assessing heart failure, but it is not the primary goal in the case of a STEMI (ST-Elevation Myocardial Infarction). In STEMI, the primary goal is to identify and treat the blockage in the coronary arteries that is causing the heart attack.

B) Determine cardiac output during the procedure:
Cardiac output is a useful measurement for assessing heart function, but it is not the main focus during the treatment of STEMI. While monitoring cardiac output may be part of the overall care, the urgent priority in STEMI management is to restore blood flow to the affected myocardial tissue as quickly as possible to minimize damage, not to measure cardiac output.

C) Evaluate the extent of the occlusion of the coronary arteries involved:
While evaluating the extent of coronary artery occlusion is part of the process during a cardiac catheterization, the immediate priority for a patient with STEMI is to treat the blockage, not just evaluate it. While the angiogram will reveal the blockage, the treatment goal is to restore perfusion to the affected area of the heart through procedures such as balloon angioplasty or stent placement.

D) Prevent extensive myocardial damage:
This is the correct answer. The main goal of treatment for STEMI is to prevent extensive myocardial damage. In a STEMI, the coronary artery is blocked, depriving the heart muscle of oxygen, which can cause significant damage or death of the myocardial tissue. The most effective way to limit the extent of damage is to restore blood flow as quickly as possible, often through emergent procedures like percutaneous coronary intervention (PCI) or fibrinolytic therapy.

A. Reduce the patient's anxiety B. Assure adequate circulating volume C. Decrease the patient's chest pain D. Maintain adequate oxygenation

Correct Answer is D

Explanation

A) Reduce the patient's anxiety:
While reducing anxiety is an important aspect of patient care, particularly in emergency situations, it is not the priority when life-threatening conditions may be present. Anxiety reduction can be addressed after ensuring that the patient’s more critical physiological needs (such as adequate oxygenation and circulation) are met.

B) Assure adequate circulating volume:
Maintaining adequate circulating volume is important, especially in trauma cases where blood loss is a concern. However, adequate oxygenation takes precedence over circulating volume in this scenario because without proper oxygenation, the patient’s vital organs and tissues may suffer from hypoxia, leading to further complications.

C) Decrease the patient's chest pain:
Chest pain following a motor vehicle accident (MVA) can be a symptom of serious injuries, such as rib fractures, pneumothorax, or even a cardiac contusion. While relieving pain is important for comfort and overall well-being, the priority in the immediate post-trauma phase is to ensure that the patient is receiving adequate oxygen.

D) Maintain adequate oxygenation:
The most critical concern after trauma, especially in a case involving chest impact, is ensuring that the patient is adequately oxygenated. Chest trauma can cause injuries to the lungs or pleural space (e.g., pneumothorax, hemothorax), leading to compromised oxygen exchange. The priority is to assess and maintain the patient's airway, breathing, and oxygenation first.

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The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

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