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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Correct Answer is B

Explanation

A. Minimal edema in the affected extremities:
Expected after 72 hours as inflammation begins to subside.

B. Temperature of 39.1°C (102.4°F):
Elevated temperature may indicate infection or systemic inflammation and should be reported.

C. Pain at the burn sites:
Pain is expected, especially in partial-thickness burns where nerve endings are exposed.

D. Urine output of 30 mL/hr:
While on the lower end of normal, this is still acceptable for an adult (minimum: 30 mL/hr).

A. Allergic reaction in patients with sulfa allergies B. Increased risk of infection C. Delayed wound healing D. Improved wound healing

Correct Answer is A

Explanation

A. Allergic reaction in patients with sulfa allergies:
Silver sulfadiazine contains a sulfa compound and is contraindicated in patients with sulfonamide allergies.

B. Increased risk of infection:
Silver sulfadiazine is antimicrobial, and reduces infection risk, not increases it.

C. Delayed wound healing:
Some studies suggest it may delay epithelialization, but this is not the most common or concerning reaction.

D. Improved wound healing:
It helps prevent infection, but does not significantly accelerate healing. The focus is on infection control, not wound closure.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who sustained superficial partial-thickness and deep partial burns 72 hours ago. Which of the following findings should the nurse report to the provider?

Correct Answer is B

Explanation

Which of the following is a potential adverse reaction to silver sulfadiazine in burn victims?

Correct Answer is A

Explanation

A nurse in a provider's office is caring for a client who has tinea pedis. Which of the following findings should the nurse expect?

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 caring for a patient with lesions on the skin. Which of the following assessment findings would cause the nurse to suspect scabies?

Which of the following factors increases the risk for infection in burn patients?

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

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

A physician orders IV normal saline solution to be infused at a rate of 150 mL/hr for a patient. How many milliliters of solution will the patient receive during an 8 hour shift. Express your answer to the nearest whole number