A client with partial-thickness burns to the trunk and both lower extremities is admitted 2 hours after injury.
Which intravenous fluid should the nurse initiate?
Albumin 2.5 percent.
Lactated Ringer's solution.
5 percent dextrose in water.
0.9 percent normal saline with 20 mEq potassium.
The Correct Answer is B
This scenario focuses on acute fluid resuscitation following thermal injury. Knowledge of fluid shift dynamics during the emergent phase of burns is essential to prevent hypovolemic shock. Crystalloid selection must prioritize electrolyte balance and volume expansion to maintain organ perfusion.
Choice A rationale
Albumin is a colloid used for volume expansion but is generally avoided in the first 24 hours of burn care. Increased capillary permeability allows large molecules to leak into interstitium, worsening edema rather than maintaining intravascular volume.
Choice B rationale
This isotonic crystalloid is the gold standard for burn resuscitation. It closely mimics extracellular fluid and provides essential electrolytes. The lactate is metabolized into bicarbonate, which helps buffer the metabolic acidosis commonly seen in major thermal injuries.
Choice C rationale
Dextrose in water is a hypotonic solution once glucose is metabolized. It does not stay in the intravascular space and can lead to cellular edema. It is ineffective for volume resuscitation and may cause dangerous electrolyte imbalances.
Choice D rationale
While normal saline is isotonic, adding potassium is contraindicated in the emergent burn phase. Damaged cells release intracellular potassium into the bloodstream, making hyperkalemia a significant risk. Normal range for potassium is 3.5 to 5.0 mEq/L.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["326.25"]
Explanation
Step 1 is 43.5 kg × 7.5 mg/kg.
Final calculated answer is 326.25
Correct Answer is A
Explanation
Chest tube management for pneumothorax involves monitoring for clinical complications and system patency. This scenario requires applying knowledge of respiratory emergencies, specifically recognizing signs of tension pneumothorax, which is a life threatening complication characterized by shifting of thoracic structures.
Choice A rationale
Tracheal deviation toward the unaffected side signifies a tension pneumothorax. This occurs when intrapleural pressure increases significantly, causing a mediastinal shift that compresses the heart and opposite lung, requiring immediate needle decompression or chest tube adjustment by providers.
Choice B rationale
Eyelets are the drainage holes at the end of the chest tube. If they are not visible, it indicates the tube is correctly positioned within the pleural space. Visible eyelets would suggest the tube has partially dislodged.
Choice C rationale
Crepitus, or subcutaneous emphysema, is a common finding where air leaks into subcutaneous tissues around the insertion site. While it should be monitored and documented, it generally does not require emergency provider notification unless it rapidly expands.
Choice D rationale
Intermittent bubbling in the water seal chamber during exhalation or coughing is expected in a patient with a pneumothorax. It indicates that air is successfully being evacuated from the pleural space into the drainage system.
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