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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Allow the client's partner to translate: Family members should not serve as interpreters due to concerns about accuracy, confidentiality, and potential bias in sensitive health information.
B. Ask a nursing student who speaks the same language as the client to translate: Using untrained personnel, including students, is discouraged because they may lack professional interpreting skills and could miscommunicate critical health information.
C. Have the client's child translate: Children are not appropriate interpreters due to their limited language skills, emotional immaturity, and potential to misinterpret medical information.
D. Request a female interpreter through the facility: A professional medical interpreter ensures accurate, confidential communication, respects cultural and gender preferences, and is the safest approach for gathering admission data, particularly regarding sensitive postpartum issues.
Correct Answer is B
Explanation
A. Hypotension: Methamphetamines are central nervous system stimulants that typically cause hypertension and tachycardia due to increased sympathetic activity, rather than low blood pressure.
B. Weight loss: Methamphetamines suppress appetite and increase metabolism, which can lead to significant weight loss. This is a common adverse effect associated with chronic use.
C. Somnolence: Stimulant effects of methamphetamines generally cause insomnia and hyperactivity rather than excessive sleepiness. Somnolence is not a typical adverse effect.
D. Lethargy: Methamphetamine use initially produces energy and euphoria. Lethargy may occur only during withdrawal, not as a direct adverse effect of active use.
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