A client with 50% full-thickness burns has received fluid resuscitation for the past 24 hours. Which assessment warrants immediate intervention by the nurse?
Average urine output of 28 mL/hour.
Vesicular bibasilar breath sounds.
Inspiratory and expiratory bilateral crackles.
Central venous pressure of 12 mm Hg.
The Correct Answer is C
The correct answer is: c. Inspiratory and expiratory bilateral crackles.
Choice A: Average urine output of 28 mL/hour
Reason: The normal urine output for an adult is typically 0.5 mL/kg/hr, which translates to about 30-50 mL/hr for most adults. An average urine output of 28 mL/hour is slightly below this range, indicating possible inadequate fluid resuscitation. However, it is not immediately life-threatening and does not warrant the most urgent intervention compared to other options.
Choice B: Vesicular bibasilar breath sounds
Reason: Vesicular breath sounds are normal lung sounds heard over most of the lung fields. They are soft and low-pitched, indicating that the airways are clear. Therefore, vesicular bibasilar breath sounds do not indicate any immediate respiratory distress or fluid overload and do not require urgent intervention.
Choice C: Inspiratory and expiratory bilateral crackles
Reason: Crackles, also known as rales, are abnormal lung sounds that indicate the presence of fluid in the alveoli. Bilateral crackles heard during both inspiration and expiration suggest significant pulmonary edema or acute respiratory distress syndrome (ARDS), which can be life-threatening and requires immediate intervention.
Choice D: Central venous pressure of 12 mm Hg
Reason: The normal range for central venous pressure (CVP) is 2-8 mm Hg. A CVP of 12 mm Hg is elevated, indicating possible fluid overload or heart failure. While this is concerning and requires monitoring, it is not as immediately critical as bilateral crackles, which directly affect oxygenation and respiratory function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Removing dentures or other oral appliances may be necessary for some medical procedures, but it is not the most important intervention for a client with OSA who has just received an opioid patch.
Choice B reason: Lifting and locking the side rails in place is a standard safety measure, but it does not directly address the respiratory concerns associated with OSA and opioid use.
Choice C reason: Applying the client's positive airway pressure device is the most important intervention. Opioids can depress respiration, and for a client with OSA, ensuring the airway is patent and supported by a positive airway pressure device is crucial to prevent respiratory complications.
Choice D reason: Elevating the head of the bed can aid in respiration, but it is not as immediately critical as ensuring the use of a positive airway pressure device for a client with OSA who is receiving opioids.
Correct Answer is A,B,C,D,E
Explanation
Choice A reason: The first step is to document the concerns for an accurate record and report them to the charge nurse to address the issue internally within the unit.
Choice B reason: If the issue is not resolved at the unit level, the next step is to discuss the matter with the physician directly as a group, which can lead to a resolution without escalating the situation.
Choice C reason: Should the problem persist, submitting a written report to the Director of Nursing is appropriate to involve higher management and seek further action.
Choice D reason: If the issue remains unresolved after involving the Director of Nursing, contacting the hospital's Chief of Medical Services is the next step to escalate the matter within the hospital's administrative structure.
Choice E reason: As a last resort, if all internal avenues have been exhausted and the problem persists, filing a formal complaint with the state medical board is necessary to address potential violations of professional conduct.
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