A nurse is caring for a patient with 40% TBSA burns who is receiving fluid resuscitation. Which of the following nursing interventions is the priority?
Weigh the patient daily to monitor fluid balance.
Monitor urine output to ensure at least 30 mL/hr.
Assess for signs of fluid deficit such as lung crackles and engorged neck veins.
Administer only colloid solutions within the first 8 hours post-burn.
The Correct Answer is B
A. Weigh the patient daily to monitor fluid balance. Daily weights are useful for tracking fluid shifts but are not the priority in the acute phase of burn management.
B. Monitor urine output to ensure at least 30 mL/hr. Urine output is a key indicator of adequate fluid resuscitation. A minimum of 30 mL/hr ensures proper kidney perfusion and prevents hypovolemia or fluid overload.
C. Assess for signs of fluid deficit such as lung crackles and engorged neck veins. Crackles and neck vein distension indicate fluid overload, not deficit. While monitoring for overload is important, urine output is the best immediate indicator of effective fluid resuscitation.
D. Administer only colloid solutions within the first 8 hours post-burn. Crystalloids (e.g., Lactated Ringer’s) are the primary fluids used in the first 24 hours post-burn. Colloids are typically introduced later.
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Related Questions
Correct Answer is D
Explanation
A. The surgical dressing has a small amount of serosanguinous drainage. Light serosanguinous drainage is expected postoperatively and does not require immediate intervention.
B. The patient’s hemoglobin dropped from 12 g/dL to 10 g/dL within 24 hours postoperatively. A mild drop in hemoglobin postoperatively is expected due to blood loss during surgery. This does not require immediate intervention.
C. The patient reports mild discomfort at the surgical site and rates pain as 4/10 on a pain scale. Mild discomfort is expected and can be managed with prescribed analgesics.
D. The surgical extremity is cool to touch, pale, with weak pedal pulses compared to the contralateral limb. These findings indicate impaired circulation or vascular compromise, which could suggest compartment syndrome or arterial occlusion. Immediate intervention is required to prevent limb ischemia.
Correct Answer is A
Explanation
A. "Allopurinol helps to lower uric acid levels and prevent future gout attacks." Allopurinol is a xanthine oxidase inhibitor that decreases uric acid production, helping to prevent future gout attacks rather than treating acute flares.
B. “I should take allopurinol during an acute gout attack to relieve pain immediately." Allopurinol is not used for acute gout attacks because it does not have immediate pain-relieving or anti-inflammatory effects. In fact, starting or increasing allopurinol during an acute attack may worsen symptoms.
C. “I should avoid drinking water while taking allopurinol to prevent kidney stones." Adequate hydration is essential while taking allopurinol to prevent uric acid kidney stones and to help eliminate excess uric acid from the body.
D. "Allopurinol works by reducing inflammation in my joints during a flare-up." Allopurinol does not have anti-inflammatory properties. It lowers uric acid levels over time, reducing the risk of future gout attacks but not treating acute inflammation.
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