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 {"A":{"answers":"B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}

Explanation

Lymphadenopathy: Generalized lymphadenopathy, or swelling of the lymph nodes, is a common symptom of measles and rubella, but not typically a defining feature of fifth disease.
Koplik spots in the mouth: Pathognomonic for measles, appearing as tiny white lesions on the buccal mucosa before the rash. Their presence essentially confirms measles over other viral exanthems.
Red rash on the face: Occurs in all three illnesses but with different patterns — measles starts at the hairline and spreads downward, rubella begins on the face and spreads quickly, and fifth disease presents with a “slapped cheek” appearance before spreading.
Fever: Common to all three conditions but differs in severity — measles typically produces higher fevers, rubella causes mild fever, and fifth disease may have low-grade fever or none.

A. Apply pressure to the lacrimal punctum. B. Place the child in a sitting position. C. Instill the drops of medication. D. Pull the lower eyelid downward.

Correct Answer is B,D,C,A

Explanation

Rationale:

B. Place the child in a sitting position: Positioning the child upright or with the head slightly tilted back promotes comfort, stability, and proper visualization of the conjunctival sac for accurate drop placement.

D. Pull the lower eyelid downward: This creates a conjunctival pocket that holds the medication and allows it to spread evenly over the eye surface without spilling.

C. Instill the drops of medication: Instillation should occur after exposing the conjunctival sac to ensure the medication reaches the target area. The dropper should not touch the eye to prevent contamination.

A. Apply pressure to the lacrimal punctum: This step is performed last to prevent systemic absorption of the medication by blocking the nasolacrimal duct. Holding gentle pressure for about 1 minute helps maximize the local effect of the drops.

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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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Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant in an outpatient pediatrician's office. Exhibits Click to specify if each finding is indicative of fifth disease, measles, or rubella. Each finding may support more than one disease process.

Correct Answer is {"A":{"answers":"B,C"},"B":{"answers":"B"},"C":{"answers":"A,B,C"},"D":{"answers":"A,B,C"}}

Explanation

A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

Correct Answer is B,D,C,A

Explanation

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