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 C

Explanation

A) Equal but sluggishly reactive pupils:
Pupillary changes, including sluggish or unequal responses, are significant signs of increasing intracranial pressure (ICP) and should be monitored closely. However, altered level of consciousness (LOC) is typically one of the earliest signs of increased ICP. The response of the pupils to light can become abnormal later, once pressure increases within the brain, particularly when brainstem function is impacted.

B) Widening pulse pressure:
A widening pulse pressure is part of Cushing’s triad, which is a late sign of increased ICP. Cushing’s triad consists of hypertension, bradycardia, and irregular respirations (often seen as Cheyne-Stokes). These changes occur in the later stages of elevated ICP as a compensatory mechanism to preserve cerebral perfusion. While this is an important finding, altered LOC would precede the development of Cushing’s triad.

C) Altered level of consciousness:
Altered level of consciousness (LOC) is typically the first and most sensitive indicator of increased ICP. As pressure increases within the skull, it compresses brain tissue and affects the brainstem, which controls basic functions like consciousness. LOC can range from mild confusion and disorientation to full loss of consciousness or coma, depending on the severity of the ICP increase.

D) Tachycardia and hypotension:
Tachycardia and hypotension can be associated with shock or other conditions, but they are not characteristic of early increased ICP. In fact, as ICP rises, the body typically responds with bradycardia (slower heart rate) and hypertension (increased blood pressure), which are part of the compensatory mechanisms.

A. Ventilator -associated pneumonia B. Pulmonary embolism C. Stress ulcer D. Pneumothorax

Correct Answer is A

Explanation

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

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