Try Naxlex NCLEX-RN (Free-Trial)

A male client who weighs 90 kg is admitted to the emergency department with full thickness burns to 45% of his total body surface area (TBSA). The burns occurred at 1000. At 1200, the nurse uses the prescribed protocol for burns fluid resuscitation to calculate the total fluid volume for the first 24 hours. The infusion pump should be set to deliver how many mL/hour during the first 8 hours? (Enter numeric value only. If rounding is required, round to the nearest whole number.)

Answer and Explanation

The Correct Answer is ["1350"]

Rationale:

Fluid resuscitation rate using the Parkland formula:

Calculate the total fluid volume needed for the first 24 hours.

The Parkland formula: 4 mL × client weight (kg) × % TBSA burned.

Client weight = 90 kg

TBSA burned = 45%

Total fluid volume = 4 mL × 90 kg × 45 = 16,200 mL

Determine the amount of fluid to be given in the first 8 hours.

According to the Parkland formula, half of the total fluid volume is administered in the first 8 hours from the time of the burn injury.

Fluid for first 8 hours = 16,200 mL / 2

= 8,100 mL

Calculate the infusion rate for the first 8 hours.

The burn occurred at 1000. The nurse arrives at 1200. This means 2 hours have already passed since the burn occurred within the initial 8-hour period.

Remaining time in the first 8 hours = 8 hours - 2 hours

= 6 hours.

Infusion rate (mL/hour) = Fluid for remaining first 8 hours / Remaining time in first 8 hours

= 8,100 mL / 6 hours

= 1350 mL/hour.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

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

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D","E","F"]

Explanation

A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.

B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.

C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.

D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.

E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.

F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.

G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.

G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.

A. Remind the client to keep his appointments to have his cholesterol level checked. B. Teach the client to weigh himself weekly and keep a log of the measurements. C. Encourage the client to keep a diary of his food intake until his next visit to the clinic. D. Assess the elasticity of the client's skin at the next scheduled clinic appointment.

Correct Answer is A

Explanation

A. Remind the client to keep his appointments to have his cholesterol level checked: Ezetimibe works by reducing cholesterol absorption in the intestines. Its effectiveness is best evaluated through changes in cholesterol levels, making lab tests crucial for monitoring its impact.

B. Teach the client to weigh himself weekly and keep a log of the measurements: While monitoring weight can be important for other conditions, it is not the primary evaluation for the effectiveness of ezetimibe, which targets cholesterol levels rather than body weight.

C. Encourage the client to keep a diary of his food intake until his next visit to the clinic: Although a food diary can be helpful for managing diet, the effectiveness of ezetimibe is best assessed through cholesterol levels rather than dietary tracking alone.

D. Assess the elasticity of the client's skin at the next scheduled clinic appointment: Skin elasticity is not directly related to the effectiveness of ezetimibe. This medication’s primary impact is on cholesterol levels, which should be monitored through lab tests.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse considers the brief interaction with the client and the triage report. Which finding(s) should the nurse investigate further? Select all that apply.

Correct Answer is ["B","C","D","E","F"]

Explanation

To evaluate the effectiveness of a male client's new prescription for ezetimibe, which action should the clinic nurse implement?

Correct Answer is A

Explanation

The nurse is preparing to obtain a rapid coronavirus (COVID-19) test for a client who was exposed to the virus eight days ago. The client is experiencing fever, cough, and shortness of breath. Which action is most important for the nurse to take?

The nurse is speaking with the spouse of a client who has passed away unexpectedly. The spouse is very calm and says, "No, there must be a mistake." Which action should the nurse take?

The nurse assesses a client being treated for Herpes zoster (shingles). Which assessment(s) should the nurse include when evaluating the effectiveness of treatment? Select all that apply.

The nurse is caring for a client who receives a prescription for parenteral lidocaine. Prior to administering the medication, the nurse should review the medical record for which condition?