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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. “Wash linens, clothes and towels.”
Scabies mites can survive for up to 2–3 days on fabrics. Washing items in hot water and drying on high heat effectively kills mites.

B. “Dry clean all linens, towels, and clothes.”
Not necessary; washing with hot water is sufficient and more accessible.

C. “Remove infested pets from the home.”
Scabies is species-specific. Human scabies mites do not live on pets.

D. “Discard infested mattresses.”
Mites cannot survive long on surfaces without human contact. Mattresses can be vacuumed and covered if needed.

A. Adequate Tissue Perfusion B. Risk for infection C. Impaired Gas Exchange D. Acute Pain E. Fluid Volume Deficit

Correct Answer is ["B","C","D","E"]

Explanation

A. Adequate Tissue Perfusion
While this important in burn management, it is not typically classified as a priority nursing diagnosis in the early stages of treatment.

B. Risk for infection
Burned skin is a lost barrier to pathogens, increasing infection risk.

C. Impaired Gas Exchange
Especially in cases of inhalation injury, airway swelling or carbon monoxide exposure can impair gas exchange.

D. Acute Pain
Burns cause significant pain that requires management for comfort and healing.

E. Fluid Volume Deficit
Burns result in fluid shifts and capillary leakage, leading to hypovolemia.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which instructions should the nurse provide to the patient being treated with scabies?

Correct Answer is A

Explanation

Priority nursing diagnoses for burns include: (Select All That Apply)

Correct Answer is ["B","C","D","E"]

Explanation

A nurse at a community center is assisting with a presentation about sun protection to a group of residents. Which of the following responses by the residents indicates an understanding of the teaching?

A nurse is caring for a client with severe burns to both lower extremities. The client is scheduled for an escharotomy and wants to know what the procedure involves. Which of the following statements is appropriate for the nurse to make?

The nurse at an HCP's office is interviewing a patient presenting with a skin infection. Which question by the nurse will provide the least important information?

The nurse is explaining to a family the benefit of a patient-controlled analgesia pump. Which of the following is an appropriate use of Dilaudid PCA for burn patients?

A nurse in the outpatient clinic is collecting data from a client who has psoriasis. Which of the following findings should the nurse expect?

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the client's skin integrity?

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.)