The nurse is taking care of a burn patient with deep partial-thickness burns. Which of the following factors can contribute to fluid imbalance in burn patients?

Decreased metabolic rate

Increased capillary permeability

Normal electrolyte levels

Excessive fluid intake

Answer and Explanation

The Correct Answer is B

A. Decreased metabolic rate:
Burns cause an increase, not decrease, in metabolic rate due to the hypermetabolic state post-injury.

B. Increased capillary permeability:
This is a hallmark of burn injuries. Damaged capillaries leak fluid into interstitial spaces, leading to fluid and electrolyte imbalance.

C. Normal electrolyte levels:
Electrolyte levels are often abnormal in burn patients due to fluid shifts and tissue damage.

D. Excessive fluid intake:
Overhydration can be harmful, but it is not a typical cause of the initial fluid imbalance seen in burns.

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Correct Answer is B

Explanation

A. Sanguineous drainage in the suction device:
May occur early on, but persistent sanguineous drainage is not a sign of healing.

B. Granulation tissue on the surface of the wound:
Granulation tissue is pink, healthy tissue that indicates wound healing.

C. Musty odor from the foam dressing upon removal:
Could indicate infection or dressing degradation, not healing.

D. Peeling of the edges of the transparent dressing:
Could compromise the seal of the VAC system and does not reflect wound healing.

A. Assist the client with physical therapy exercises B. Administer pain medication as ordered C. Monitor for signs of infection D. Educate the client about the importance of sun protection and skin checks

Correct Answer is D

Explanation

A. Assist the client with physical therapy exercises:
May be useful postoperatively or in metastatic cases, but not a priority intervention specific to melanoma.

B. Administer pain medication as ordered:
Important if there's pain, but melanomas are often painless. This is supportive, not specific.

C. Monitor for signs of infection:
More relevant post-surgery or chemotherapy, not specific to melanoma management.

D. Educate the client about the importance of sun protection and skin checks:
Prevention and early detection are essential for reducing recurrence and catching new melanomas early.

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The nurse is taking care of a burn patient with deep partial-thickness burns. Which of the following factors can contribute to fluid imbalance in burn patients?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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