The nurse is providing care for a patient who is receiving fluid replacement after being burned on 37 percent of the body. Nursing assessment reveals a blood pressure of 80/60 mm Hg. pulse of 120 beats/min, and urine output of 10 mL over the past hour. After reporting these findings, which order does the nurse expect to be prescribed for this patient?

Change the IV fluid to dextrose and water.

Discontinue the IV fluid infusion.

Increase the amount of IV fluid administered per hour.

Decrease the amount of IV fluid administered per hour.

Answer and Explanation

The Correct Answer is C

A. Change the IV fluid to dextrose and water:
Hypotonic solutions like D5W are not used in early burn resuscitation. They worsen edema and are not effective for volume expansion.

B. Discontinue the IV fluid infusion:
The patient shows signs of hypovolemic shock and urgently needs more fluid, not less.

C. Increase the amount of IV fluid administered per hour:
The patient has hypotension, tachycardia, and oliguria, indicating inadequate perfusion and fluid resuscitation. The appropriate response is to increase IV fluids per burn resuscitation protocols (e.g., Parkland formula).

D. Decrease the amount of IV fluid administered per hour:
Would worsen hypoperfusion and is contraindicated based on the client's vital signs.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Apply dry, sterile gauze dressings to affected areas
Shingles lesions are usually left open to air or covered with non-adherent dressings. Dry gauze may adhere to lesions and cause trauma.

B. Prepare to administer acyclovir
Acyclovir is an antiviral medication used to reduce severity and duration of herpes zoster (shingles) symptoms.

C. Apply topical corticosteroids to the affected areas
Topical corticosteroids are not recommended for herpes zoster as they can worsen viral infections.

D. Instruct family with a history of chickenpox that they should not visit the client
People who have had chickenpox are immune to varicella-zoster virus and can visit safely. Only individuals without prior exposure or vaccination should avoid contact.

A. A client who has swelling and tenderness around the wound B. A client who has urticaria and itching around the wound C. A client who has serosanguineous drainage from the wound D. A client who has brown crusting over the wound

Correct Answer is A

Explanation

A. Swelling and tenderness around the wound:
These are classic signs of infection, indicating inflammation and possible bacterial invasion.

B. Urticaria and itching around the wound:
These are signs of an allergic reaction, not infection.

C. Serosanguineous drainage from the wound:
This is normal wound drainage, especially in early healing.

D. Brown crusting over the wound:
This may indicate scab formation or dried exudate, not necessarily infection.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has herpes zoster. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is collecting data from four clients who have wounds. The nurse should recognize that which of the following clients has a manifestation of a wound infection?

Correct Answer is A

Explanation

A patient is brought to the emergency department after a house fire. the patient has extensive trunk and lower extremity burns and is diagnosed with a full thickness burn. What assessment findings does the nurse expect?

A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns to the lower extremities? Select all that apply.

A nurse is collecting data from a client who has contact dermatitis of the neck and upper chest. Which of the following findings should the nurse expect?

A nurse is preparing to administer liquid mycostatin 600,000 units PO every 8 hr. Available is mycostatin 100,000 units/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number.)

A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?

The nurse is reviewing the care plan with the dietician or nutritionist for a burn client. The nurse knows which of the following factors contribute to the increased metabolic demands in burn patients?

While collecting data on a patient, the nurse observes that the patient's facial skin is reddened and is covered with greasy scales, yellowish crusts. What skin disorder does the nurse expect the patient to be treated for?