A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)

Blood pressure

Bowel sounds

Level of consciousness

Urine output

Platelet count

Answer and Explanation

Correct Answer : A,C,D

A. Blood pressure:

Monitoring blood pressure is a crucial aspect of evaluating fluid resuscitation in burn patients. Adequate fluid resuscitation should help maintain stable blood pressure levels within an acceptable range. Hypotension (low blood pressure) can indicate inadequate fluid resuscitation, leading to poor tissue perfusion and organ function. On the other hand, hypertension (high blood pressure) may suggest fluid overload, which can lead to complications such as pulmonary edema. Therefore, regular monitoring of blood pressure helps assess the effectiveness of fluid resuscitation and guides adjustments in fluid administration rates.

B. Bowel sounds:

While bowel sounds are important indicators of gastrointestinal motility and function, they are not directly used to evaluate the success of fluid resuscitation in burn patients. Bowel sounds may be assessed for other reasons, such as postoperative recovery or gastrointestinal conditions, but they do not provide specific information about fluid resuscitation status or tissue perfusion.

C. Level of consciousness:

Assessing the client's level of consciousness is crucial during fluid resuscitation for burns. Changes in consciousness, such as confusion, lethargy, or altered mental status, can indicate inadequate tissue perfusion and oxygenation. A clear and responsive level of consciousness suggests adequate fluid resuscitation and perfusion to vital organs, while alterations in consciousness may prompt further evaluation and adjustment of fluid resuscitation strategies.

D. Urine output:

Monitoring urine output is a key parameter in evaluating fluid resuscitation in burn patients. Adequate urine output (0.5 to 1 mL/kg/hr in adults) indicates sufficient renal perfusion and function, suggesting effective fluid resuscitation. Decreased urine output or oliguria may indicate inadequate fluid resuscitation, renal impairment, or hypovolemia, requiring reassessment and potential adjustments in fluid administration rates or type of fluids used.

E. Platelet count:

Platelet count is an important component of the complete blood count (CBC) and is used to assess clotting function and risk of bleeding. However, platelet count is not specifically used to evaluate the success of fluid resuscitation in burn patients. While clotting parameters may be monitored in burn patients, including platelet count, they are not direct indicators of fluid resuscitation status or tissue perfusion. Other laboratory parameters, such as hemoglobin, hematocrit, electrolyte levels, and arterial blood gases, may be monitored to assess the effectiveness of fluid resuscitation.

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Correct Answer is C

Explanation

A. Increase the effectiveness of the skin graft:

Debridement can indeed increase the effectiveness of a skin graft by preparing a clean, viable wound bed for grafting. Removing dead tissue and debris helps the skin graft adhere to healthy tissue and promotes successful graft take. However, this is not the primary purpose of debridement.

B. Promote movement in the affected area:

While debridement can indirectly contribute to promoting movement by improving wound healing and reducing pain, the primary purpose of debridement is not to promote movement in the affected area.

C. Prevent infection and promote healing:

This statement accurately reflects the primary purpose of debridement. By removing nonviable tissue, debris, and foreign material from the wound, debridement helps prevent infection by reducing the bacterial load and creating an environment conducive to healing. It also promotes granulation tissue formation and wound contraction, which are essential for wound healing.

D. Promote suppuration of the wound:

Suppuration refers to the formation and discharge of pus from a wound, often indicating infection. Debridement aims to remove necrotic tissue and prevent infection, so promoting suppuration is not a desired outcome of debridement.

A. Melanoma B. Keloid C. Nevus D. Angioma

Correct Answer is B

Explanation

A. Melanoma:

Melanoma is a type of skin cancer that arises from melanocytes, the cells that produce pigment (melanin) in the skin. Melanoma lesions are typically irregularly shaped, often asymmetrical, with varying shades of color (brown, black, tan, red, blue). They may have an uneven border and can evolve over time. Melanomas can be raised but are not typically described as indurated (firm) and shiny. They are also more commonly associated with changes in color, size, and shape.

B. Keloid:

A keloid is an abnormal overgrowth of scar tissue that extends beyond the boundaries of the original wound or incision site. Keloids are characterized by their raised appearance, firm or indurated texture, and shiny surface compared to the surrounding skin. They may also be darker than the surrounding skin due to increased collagen deposition. Keloids can develop months after an injury or surgery and are more common in individuals with darker skin tones, such as African Americans.

C. Nevus:

A nevus, commonly known as a mole or birthmark, is a benign growth of melanocytes or other skin cells. Nevus lesions can vary in appearance but are often flat or slightly raised, with a uniform color (brown, black, tan, or flesh-colored). They are usually not described as indurated or shiny. Nevus lesions can be present at birth (congenital nevus) or develop later in life (acquired nevus).

D. Angioma:

Angiomas are benign tumors that originate from blood vessels or lymphatic vessels. They can present as red or purplish raised lesions on the skin. Angiomas are typically not described as indurated or shiny. Common types of angiomas include cherry angiomas (small, red papules) and spider angiomas (red, spider-like lesions with central vessels).

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A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)

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Correct Answer is C

Explanation

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Correct Answer is B

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