The nurse is providing care to a client who sustained burns to 70% of the body 6 hours ago. Which of the following new assessment data requires the nurse to notify the healthcare provider?
Heart rate of 90 bpm.
Blood pressure of 96/50 mm Hg.
Urine output of 2 mL/kg per hour
Pain rating of 7 on a 1 to 10 point scale.
The Correct Answer is B
A. Heart rate of 90 bpm: While an elevated heart rate may be expected in response to burn injury and the body's stress response, a heart rate of 90 bpm alone may not be concerning without additional context.
B. Blood pressure of 96/50 mm Hg: This blood pressure reading indicates hypotension, which can be a sign of inadequate tissue perfusion, fluid loss, or shock. It requires prompt notification of the healthcare provider for further assessment and intervention.
C. Urine output of 2 mL/kg per hour: Adequate urine output is important for renal function and fluid balance, and a urine output of 2 mL/kg per hour is within the normal range. While changes in urine output should be monitored, this finding alone does not require immediate notification of the healthcare provider.
D. Pain rating of 7 on a 1 to 10 point scale: Pain management is important in burn care, but a pain rating of 7 on a 1 to 10 scale is not unusual in clients with burns and may not require immediate notification of the healthcare provider unless accompanied by other concerning symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Morphine sulfate 2 mg IV bolus every 2 hr PRN pain: This prescription is appropriate for managing pain associated with acute heart failure and MI.
B. Bumetanide 1 mg IV bolus every 12 hr: Bumetanide is a loop diuretic commonly used in heart failure to reduce fluid overload. However, the frequency of administration (every 12 hours) may not be sufficient for managing acute heart failure, where more frequent dosing may be necessary initially.
C. Laboratory testing of serum potassium upon admission: This is a routine and appropriate order to monitor electrolyte balance, especially with the use of diuretics.
D. 0.9% normal saline IV at 75 mL/hr: This is a maintenance IV fluid rate that may be appropriate depending on the client's fluid status. However, it does not directly address acute heart failure.
Correct Answer is B
Explanation
A. Wheezing in all lung fields may indicate respiratory issues but does not directly support the diagnosis of Excess Fluid Volume.
B. Pitting edema in bilateral lower extremities is a classic sign of fluid overload, which directly supports the diagnosis of Excess Fluid Volume.
C. An oral fluid intake of 2000 mL in 24 hours is within normal limits for an adult and does not necessarily indicate Excess Fluid Volume without other symptoms.
D. Significant fatigue for more than one month could be related to a variety of conditions and is too nonspecific to support the diagnosis of Excess Fluid Volume without additional assessment data.
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