A nurse in the emergency department is caring for a client who has major burns. Which of the following actions should the nurse take?

Administer fluid bolus immediately when the client arrives to the facility.

Administer one-third of the total fluid volume for resuscitation within the first 12 hr.

Calculate fluid volume for resuscitation beginning with client arrival time at the facility.

Use the total body surface area of the client's burns when calculating fluid volume for resuscitation.

Answer and Explanation

The Correct Answer is D

A. Administer fluid bolus immediately when the client arrives to the facility: Rapid fluid boluses are reserved for clients in hypovolemic shock. For burn resuscitation, fluids are calculated and administered according to formulas rather than as a one-time bolus.

B. Administer one-third of the total fluid volume for resuscitation within the first 12 hr: Burn fluid resuscitation formulas, such as the Parkland formula, typically require half of the total calculated fluids to be given within the first 8 hours post-burn, not 12 hours.

C. Calculate fluid volume for resuscitation beginning with client arrival time at the facility: Fluid calculation is based on the time of the burn occurrence, not the arrival time, to ensure accurate resuscitation over the initial 24 hours.

D. Use the total body surface area of the client's burns when calculating fluid volume for resuscitation: The extent of burns, expressed as a percentage of total body surface area (TBSA), is a key factor in calculating fluid needs. Accurate TBSA assessment ensures appropriate fluid resuscitation to maintain perfusion and prevent complications.

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Correct Answer is C

Explanation

A. 1 cup sliced peaches: Peaches contain some vitamin C but in lower amounts compared with other fruits. They are not the highest source for meeting daily vitamin C needs in toddlers.

B. 1 cup sliced banana: Bananas provide minimal vitamin C and are better known for their potassium content. They are not an effective choice for significantly increasing vitamin C intake.

C. 1 cup sliced kiwifruit: Kiwifruit is exceptionally high in vitamin C, providing more than the daily requirement for a toddler in a single cup. It is an excellent choice for boosting vitamin C intake.

D. 1 cup cubed cantaloupe: Cantaloupe contains vitamin C but in moderate amounts. While beneficial, it is less concentrated than kiwifruit for meeting vitamin C needs.

A. "This medication can cause back pain." B. "Avoid taking this medication with milk products." C. "Use an electric razor when shaving while taking this medication." D. "Avoid prolonged exposure to sunlight while taking this medication."

Correct Answer is C

Explanation

Rationale:

A. "This medication can cause back pain.": Back pain is not a common or expected adverse effect of warfarin. Teaching should focus on bleeding risks and precautions rather than unrelated symptoms.

B. "Avoid taking this medication with milk products.": Milk does not significantly affect warfarin absorption. The main dietary consideration is maintaining consistent vitamin K intake, as large fluctuations can alter anticoagulation.

C. "Use an electric razor when shaving while taking this medication.": Warfarin increases the risk of bleeding and bruising. Using an electric razor reduces the chance of cuts, promoting safety during routine grooming.

D. "Avoid prolonged exposure to sunlight while taking this medication.": Sun exposure is not contraindicated with warfarin; there is no significant interaction between warfarin and UV light.

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A nurse in the emergency department is caring for a client who has major burns. Which of the following actions should the nurse take?

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