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 B
Explanation
Rationale:
A. Educate clients who are at risk for Parkinson's disease about maintaining a low-cholesterol diet: This is an example of primary prevention, aimed at reducing risk factors before the onset of disease, rather than tertiary prevention.
B. Provide daily exercise classes to improve ambulation for patients who have Parkinson's disease: Tertiary prevention focuses on managing disease, minimizing complications, and improving quality of life for those already diagnosed. Exercise programs help maintain mobility and prevent further functional decline.
C. Educate clients about common techniques used to diagnose Parkinson's disease: Teaching about diagnostic techniques is related to secondary prevention, which focuses on early detection and timely intervention.
D. Provide screenings for community members to identify early manifestations of Parkinson's disease: Screening is a secondary prevention strategy intended to detect disease early in asymptomatic individuals, not tertiary prevention.
Correct Answer is A
Explanation
Rationale:
A. Perform a sterile dressing change for a client who has an abdominal wound: LPNs can perform sterile procedures and wound care on stable clients, making this an appropriate delegated task.
B. Complete the Glasgow Coma Scale for a client who has an evolving stroke: Neurological assessments on unstable or acutely changing clients require RN judgment and should not be delegated to an LPN.
C. Perform an admission assessment for a client who is scheduled for surgery: Admission assessments require comprehensive data collection, interpretation, and nursing judgment, which fall under the RN scope of practice.
D. Complete discharge teaching for a client who has a new diagnosis of diabetes mellitus: Discharge teaching for a new condition involves complex education and evaluation of understanding, which are RN responsibilities.
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