Which of the following indicates that fluid resuscitation may be inadequate?

Urine output of 10 mL/h

Urine output of 50 mL/h

Respiratory rate of 16

Blood pressure of 120/80 mmHg

Answer and Explanation

The Correct Answer is A

Rationale:
A. Urine output of 10 mL/h is correct because oliguria (urine output < 0.5 mL/kg/h or roughly < 30 mL/h in adults) is a key indicator of inadequate perfusion and insufficient fluid resuscitation. In burn or shock patients, adequate fluid resuscitation is essential to maintain renal perfusion and prevent acute kidney injury. A urine output of 10 mL/h suggests hypoperfusion and ongoing intravascular volume deficit.

B. Urine output of 50 mL/h is incorrect because this indicates adequate renal perfusion and suggests that fluid resuscitation is likely sufficient. This meets or exceeds the target urine output for most critically ill patients.

C. Respiratory rate of 16 is incorrect because this is within normal limits (12–20 breaths/min) and does not indicate hypovolemia or inadequate fluid resuscitation.

D. Blood pressure of 120/80 mmHg is incorrect because this is a normal blood pressure. While hypotension can be a late sign of inadequate fluid resuscitation, a normal BP does not necessarily indicate inadequate resuscitation on its own, especially in early shock where compensatory mechanisms maintain BP.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:

A. 25 kcal/kg/day – Partially correct but represents the lower end of the range and may not meet needs for all mildly stressed patients.
B. 30–35 kcal/kg/day – Incorrect for mild stress; this range is more appropriate for moderate to severe stress or hypermetabolic states.
C. 40 kcal/kg/day – excessive for mild stress and may contribute to overfeeding complications.
D. 25–30 kcal/kg/day – Caloric requirements for critically ill patients vary depending on the level of metabolic stress. Mildly stressed patients generally require 25–30 kcal/kg/day to maintain energy balance and support healing. This range accounts for the increased metabolic demands without overfeeding, which can lead to complications such as hyperglycemia or increased CO₂ production.

A. Monitor vital signs every 15 minutes B. Place the patient in high Fowler's position C. Notify the physician and prepare for intubation D. Administer high-flow oxygen via non-rebreather mask

Correct Answer is C

Explanation

Rationale:

A. Monitoring vital signs every 15 minutes is incorrect because while ongoing monitoring is important, this patient is showing signs of impending airway obstruction, which requires immediate intervention. Simply monitoring is not sufficient.

B. Placing the patient in high Fowler’s position is incorrect because positioning may help with comfort and breathing, but it does not address the critical airway threat posed by inhalation injury or upper airway edema.

C. Notifying the physician and preparing for intubation is correct because hoarseness, stridor, and difficulty speaking are early indicators of airway compromise due to inhalation injury or facial burns. Airway edema can progress rapidly, making early, controlled intubation the priority before the airway becomes completely obstructed.

D. Administering high-flow oxygen via non-rebreather mask is incorrect as the sole intervention because oxygen alone will not prevent airway obstruction. While supplemental oxygen may be supportive, the priority is securing the airway.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Which of the following indicates that fluid resuscitation may be inadequate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for the critical care patient who is mildly stressed. Which caloric requirements are appropriate?

Correct Answer is D

Explanation

Your patient with facial burns from a house fire is being assessed in the Emergency Department. He begins to develop hoarseness, stridor, and difficulty speaking. What is the priority nursing action?

Correct Answer is C

Explanation

What are the defining characteristics the nurse assesses for in status epilepticus? (Select all that apply)

A patient with pancreatic cancer has been admitted to the critical care unit with clinical signs consistent with syndrome of inappropriate secretion of antidiuretic hormone. Which clinical management strategy does the nurse anticipate for this condition?

ICU psychosis lasts about how many days?

What does the nurse caring for a patient with acute pancreatitis do to provide adequate pain control?

The nurse is assessing a patient being admitted with fatigue and shortness of breath as well as abdominal tenderness who presents with jaundice and an enlarged liver. What does the nurse suspect that the patient has?

As the nurse cares for a patient who has delirium, what characteristics are expected in the hypoactive delirium state?

What is the normal intracranial pressure (ICP) range the nurse tries to maintain?

The nurse is caring for a patient who sustained rib fractures with dropping Sa02 and BP. The nurse assesses that breath sounds are absent throughout the left lung fields. The nurse notifies the physician and anticipates which order?