A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?
Urine output is greater than 0.5 mL/kg/hr
Serum hemoglobin is 11 gm/dL
Breath sounds are clear bilaterally
Heart rate is 122/min
The Correct Answer is A
A. Urine output is greater than 0.5 mL/kg/hr
During the fluid resuscitation phase of burn management, one of the primary goals is to maintain adequate tissue perfusion and organ function by ensuring sufficient fluid intake. The best method for assessing the results of fluid resuscitation is by monitoring urine output. A urine output of greater than 0.5 mL/kg/hr is indicative of adequate renal perfusion and kidney function, suggesting that fluid resuscitation is effective in maintaining tissue perfusion and preventing complications such as acute kidney injury.
B. Serum hemoglobin is 11 gm/dL
Serum hemoglobin levels can be affected by various factors, including fluid resuscitation, blood loss, and other medical conditions. While monitoring hemoglobin levels is important in overall patient assessment, it is not the best method specifically for assessing the results of fluid resuscitation during the initial phase of burn management.
C. Breath sounds are clear bilaterally
Clear bilateral breath sounds indicate adequate lung function and ventilation but may not directly reflect the effectiveness of fluid resuscitation in maintaining tissue perfusion. Lung sounds can be influenced by factors such as lung injury from smoke inhalation or mechanical ventilation settings, which may not correlate directly with fluid resuscitation outcomes.
D. Heart rate is 122/min
Heart rate can be influenced by various factors such as pain, stress, medications, and underlying medical conditions. While monitoring heart rate is important in assessing patient status, it is not the most reliable method for specifically evaluating the results of fluid resuscitation during the fluid resuscitation phase of burn management.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Stage III pressure injury
Stage III pressure injuries involve full-thickness skin loss, extending into the subcutaneous tissue but not through the fascia. These wounds typically present as deep craters and may involve undermining or tunneling. Non-blanchable erythema alone without visible skin loss is not characteristic of a Stage III pressure injury.
B. Stage IV pressure injury
Stage IV pressure injuries are the most severe and involve full-thickness tissue loss with exposed bone, tendon, or muscle. These wounds often have extensive tissue damage and can be difficult to manage. Again, non-blanchable erythema without visible skin loss is not indicative of a Stage IV pressure injury.
C. Stage II pressure injury
Stage II pressure injuries involve partial-thickness skin loss with damage to the epidermis and possibly the dermis. These wounds often present as shallow open ulcers or blisters and may have characteristics such as intact or ruptured blisters. While Stage II injuries can present with erythema, non-blanchable erythema specifically indicates a Stage I injury.
D. Stage I pressure injury
Stage I pressure injuries are the earliest stage and involve non-blanchable erythema of intact skin. The skin may be warmer or cooler than surrounding tissue and may have changes in sensation. There is no visible skin loss at this stage, but the area is at risk for further injury if pressure is not relieved. Therefore, non-blanchable erythema on the heels most likely indicates a Stage I pressure injury.
Correct Answer is C
Explanation
A. Superficial infections are caused by fungus.
While fungal infections can indeed cause superficial skin infections like tinea (ringworm) or candidiasis, they are not the common factor for the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions primarily involve bacterial infections of the hair follicles, typically caused by Staphylococcus aureus bacteria.
B. Parasites get underneath the skin.
Parasitic infections can cause various skin conditions, but they are not the common factor for folliculitis, furuncles, and carbuncles. These conditions are specifically related to bacterial infections of the hair follicles rather than parasitic infestations.
C. Hair follicles are infected or inflamed.
This is the correct choice and the common factor for folliculitis, furuncles, and carbuncles. All three conditions involve the infection or inflammation of hair follicles, primarily due to Staphylococcus aureus bacteria. Folliculitis is the inflammation of one or more hair follicles, furuncles are deeper infections involving the hair follicle and surrounding tissue, and carbuncles are clusters of interconnected furuncles with deeper tissue involvement.
D. There is an allergic response to an allergen.
An allergic response to an allergen does not play a role in the etiology and pathophysiology of folliculitis, furuncles, and carbuncles. These conditions are primarily infectious in nature, involving bacterial colonization and subsequent inflammation of the hair follicles rather than an allergic response.
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