A nurse is caring for a client who has full-thickness burns over 75% of his body. The nurse should use which of the following methods to monitor the cardiovascular system?
Auscultate cuff blood pressure.
Monitor the pulmonary artery pressure.
Palpate pulse pressure.
Obtain a central venous pressure.
The Correct Answer is B
A. Auscultating blood pressure may not be as reliable in burn patients due to fluid shifts and potential damage to peripheral tissues.
B. Monitoring pulmonary artery pressure provides crucial information about the cardiovascular system's status, including fluid balance and cardiac function, which are essential in the care of clients with severe burns.
C. Palpating pulse pressure alone is insufficient for thorough cardiovascular monitoring in critically ill burn patients.
D. Central venous pressure provides information about fluid status but does not offer the comprehensive cardiovascular data needed for extensive burn management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","E","F"]
Explanation
A. Heart rate: The increased heart rate (108/min) may indicate a developing complication such as hypovolemia or pain. This requires monitoring as it could signal deteriorating status.
B. Oxygen saturation: The SpO₂ level is stable at 96%, which is within an acceptable range and does not indicate an immediate concern.
C. Edema: The increase in sacral and iliac region edema (2+) from day 1 to day 2 suggests worsening swelling and possible fluid accumulation, which could be affecting blood flow and leading to circulatory issues.
D. Temperature: The temperature remains within a normal range, so it does not require immediate intervention.
E. Urine color: Dark, reddish-brown urine suggests possible bleeding or rhabdomyolysis, both of which require immediate follow-up to prevent further complications and assess kidney function.
F. Pedal pulses: The change to 1+ pedal pulses bilaterally and the delayed capillary refill time (6 seconds) indicate reduced perfusion to the lower extremities, which may suggest compromised circulation or increased edema affecting blood flow.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"A"}
Explanation
Option 1: Intracranial hemorrhage: The client’s recent fall, worsening headache, unilateral pupil dilation, right-sided weakness, and decreasing Glasgow Coma Scale (GCS) indicate a potential neurological injury, which is concerning for intracranial hemorrhage.
Option 2: Glasgow Coma Scale: The client's GCS has progressively declined (from 15 to 13), indicating a decrease in neurological function, which is critical in assessing intracranial pressure and risk for hemorrhage.
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