A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

Slow the rate to 50 mL/hr.

Increase the rate to 250 mL/hr.

Slow the rate to 20 mL/hr.

Continue the rate at 125 mL/hr.

Answer and Explanation

The Correct Answer is C

Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased ﬂuid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the ﬂuid intake of the client with head injury to avoid worsening the condition.

Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause ﬂuid overload, which can also increase the ICP and worsen the cerebral edema. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, the nurse should avoid giving too much ﬂuid to the client with head injury.

Choice C Reason: This choice is correct because slowing the rate to 20 mL/hr may help to maintain adequate hydration and electrolyte balance, while preventing ﬂuid overload and cerebral edema. This is a conservative approach that can be used until the client's neurological status and ICP are assessed and monitored.

Choice D Reason: This choice is incorrect because continuing the rate at 125 mL/hr may not be appropriate for the client with head injury, depending on their individual needs and condition. The nurse should adjust the ﬂuid rate according to the client's vital signs, urine output, serum osmolality, and ICP. Therefore, the nurse should not assume that this rate is optimal for the client without further evaluation.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because hypertension is a condition of high blood pressure. A client who has hypovolemic shock is more likely to have hypotension, which is a condition of low blood pressure, due to ﬂuid loss and reduced cardiac output.

Choice B Reason: This is incorrect because bradypnea is a condition of slow breathing. A client who has hypovolemic shock is more likely to have tachypnea, which is a condition of fast breathing, due to hypoxia and increased respiratory demand.

Choice C Reason: This is correct because oliguria is a condition of low urine output. A client who has hypovolemic shock may have oliguria due to decreased renal perfusion and activation of the renin-angiotensin-aldosterone system, which causes sodium and water retention.

Choice D reason: This is incorrect because ﬂushing of the skin is a condition of redness and warmth of the skin. A client who has hypovolemic shock may have pallor and coolness of the skin due to vasoconstriction and reduced blood ﬂow.

A. Infection B. Airway obstruction C. Paralytic ileus D. Fluid imbalance

Correct Answer is B

Explanation

Choice A Reason: Infection is a serious complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should monitor the client's wound healing, temperature, white blood cell count, and signs of sepsis, and administer antibiotics as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice B Reason: Airway obstruction is the priority risk for assessment and intervention for a client who has burns of the head, neck, and chest. The nurse should assess the client's airway patency, respiratory rate, oxygen saturation, breath sounds, and signs of respiratory distress, such as stridor, wheezes, or cyanosis. The nurse should also provide humidified oxygen, suction secretions, elevate the head of the bed, and prepare for endotracheal intubation if needed. Airway obstruction can occur due to edema, inﬂammation, or inhalation injury of the upper airway, and can quickly lead to hypoxia, respiratory failure, and death.

Choice C Reason: Paralytic ileus is a potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's bowel sounds, abdominal distension, nausea, vomiting, and stool output, and administer ﬂuids, electrolytes, and nutritional support as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

Choice D Reason: Fluid imbalance is another potential complication of burn injuries, but not the priority risk for assessment and intervention. The nurse should assess the client's ﬂuid status, urine output, vital signs, weight, and serum electrolytes, and administer intravenous ﬂuids as prescribed. However, these measures are secondary to ensuring adequate oxygenation and ventilation.

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A nurse in the emergency department is caring for a client who has sustained a head injury. The nurse notes the client's IV ﬂuids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?

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A nurse is caring for a client who has hypovolemic shock. Which of the following should the nurse recognize as an expected finding?

Correct Answer is C

Explanation

A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct Answer is B

Explanation

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