A client who was rescued from a house fire is admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs. The
nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident. Which physiological response is promoted by the administration of the fluids?

Fluid resuscitation due to capillary leaking.

Replacement of insensible water loss.

Extension of plasma until blood is available.

Restoration of electrolyte balance.

Answer and Explanation

The Correct Answer is A

Rationale

A. In the early phase following a burn injury, there is increased capillary permeability due to the release of inflammatory mediators. This results in fluid shifting from the intravascular space into the interstitial space (capillary leaking), leading to hypovolemia and decreased tissue perfusion. Administering crystalloid fluids helps to restore intravascular volume (fluid resuscitation) and improve tissue perfusion.

B. Burn injuries can lead to increased evaporative water loss through damaged skin (insensible water loss). Crystalloid fluids help to replace this lost fluid and maintain adequate hydration status in the client.

C. In severe burn injuries, there may be a need for blood transfusions due to hemorrhage or ongoing blood loss. Crystalloid fluids can help to extend plasma volume temporarily until blood products are available for transfusion, thereby supporting circulatory stability.

D. Burn injuries can disrupt electrolyte balance due to fluid shifts and tissue damage. Crystalloid fluids contain electrolytes (such as sodium and chloride) that help to restore and maintain electrolyte balance in the body.

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Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

A. Destruction of joint cartilage. B. Systemic inflammatory response. C. Loss of bone mineral density. D. Infectious process in the synovial fluid.

Correct Answer is A

Explanation

Rationale

A. Osteoarthritis is characterized by the gradual destruction of joint cartilage. Cartilage serves as a cushion between the bones in a joint, and its deterioration leads to pain, stiffness, and reduced joint function. As the cartilage wears away, bones may rub directly against each other, causing further pain and damage.

B. Osteoarthritis is primarily a degenerative condition rather than an inflammatory one. While mild inflammation can occur in OA, it is not as prominent as in autoimmune conditions like rheumatoid arthritis. In OA, inflammation is secondary to cartilage damage rather than a primary driver of the disease process.

C. Loss of bone mineral density is more characteristic of osteoporosis, a condition where bones become weak and brittle. Osteoporosis involves a decrease in bone mass throughout the skeleton, whereas osteoarthritis specifically targets the joints and affects cartilage rather than bone density.

D. An infectious process in the synovial fluid could indicate septic arthritis, which is characterized by infection in the joint space. This is typically associated with acute symptoms such as severe joint pain, swelling, warmth, and fever.

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Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is C

Explanation

An older client with osteoarthritis reports increasing pain and stiffness in the right knee and asks how to reduce these symptoms. In responding to the client, the nurse recognizes what pathology as the cause of the symptoms?

Correct Answer is A

Explanation

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

Exhibits After the nurse assesses the client, the healthcare provider writes prescriptions. The nurse reviews the prescriptions. Which 2 prescriptions should the nurse complete first?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Which instruction should the nurse provide to a client who is preparing to have a cystoscopy?

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis. Which expected outcome has the highest priority for this client?

The nurse caring for a child with mononucleosis can expect the child to exhibit which symptoms?

Exhibits The nurse is reviewing the client's chart. For each finding, click to indicate whether findings suggest that the client's condition has improved or put the client at risk for hypovolemia. Each column must have at least one selection.