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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Correct Answer is B

Explanation

Rationale

A. Benzodiazepine antagonists, such as flumazenil, are used to reverse the effects of benzodiazepines in cases of overdose or excessive sedation. However, in the context of using temazepam for insomnia, this is not a standard approach.

B. Benzodiazepines like temazepam should not be stopped abruptly, especially if they have been taken regularly. Abrupt cessation can lead to withdrawal symptoms, including rebound insomnia, anxiety, agitation, and potentially seizures in severe cases.

C. This option addresses the symptom of feeling "hungover" or fatigued the next day after taking temazepam. It acknowledges that residual sedation or drowsiness can occur with temazepam use. The nurse can educate the client about the potential for these side effects and suggest allowing for adequate time for sleep to alleviate these symptoms.

D. Stopping temazepam abruptly is not recommended because it can lead to withdrawal symptoms and potentially worsen insomnia. This option does not address the need for tapering off the medication or managing the symptoms effectively.

A. Granola, strawberries, and tea. B. Buttered whole wheat toast and coffee. C. Oatmeal, banana, and herbal tea. D. Sausage, poached eggs, and milk.

Correct Answer is C

Explanation

Rationale

A. Granola and strawberries may be high in fiber, which could potentially worsen diarrhea in some individuals. Tea is generally fine, but it should be non-caffeinated to avoid further irritation to the digestive system.

B. Whole wheat toast can be a good option as it provides carbohydrates for energy without being too heavy. However, coffee is caffeinated and can stimulate bowel movements and increase gastric acid secretion, potentially aggravating diarrhea.

C. Oatmeal is gentle on the stomach and provides soluble fiber, which can help absorb water and bulk up stools. Banana is a good source of potassium, which may be lost during episodes of diarrhea. Herbal tea is non-caffeinated and can help hydrate.

D. Sausage and milk can be high in fat and lactose, which may be difficult to digest, especially during diarrhea. Poached eggs are generally well tolerated, but the overall combination may not be ideal for someone with diarrhea.

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Naxlex Comprehensive Predictor Exams

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Correct Answer is B

Explanation

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

Correct Answer is C

Explanation

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

A client receives a prescription for 1 L of lactated Ringer's IV to be infused over 12 hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)

Patient Data Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress,

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPS. Which intervention should the home health nurse implement to ensure adequate care for all clients?

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