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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Administer antibiotics to the client. Osteomyelitis is a severe bone infection that requires immediate antibiotic therapy to eliminate the infection and prevent complications such as sepsis or bone necrosis.
B. Teach relaxation breathing to reduce the client’s pain. Pain management is important, but it does not address the underlying cause of osteomyelitis. Treating the infection is the priority.
C. Increase the client’s protein intake. A high-protein diet can promote healing, but it does not directly treat the infection and is not the priority intervention.
D. Provide the client with antipyretic therapy. Fever management is beneficial, but treating the underlying infection with antibiotics is more important than simply reducing fever.
Correct Answer is A
Explanation
A. Stage I. A Stage I pressure ulcer is characterized by intact skin with non-blanchable erythema. The affected area may feel warmer or firmer than surrounding skin.
B. Stage II. A Stage II pressure ulcer involves partial-thickness skin loss, often presenting as a shallow open ulcer or intact/blistered skin. Since the skin is still intact in this scenario, it is not Stage II.
C. Stage III. A Stage III pressure ulcer involves full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle. This does not match the description of an intact but reddened area.
D. Stage IV. A Stage IV pressure ulcer involves full-thickness tissue loss with exposed bone, tendon, or muscle. This is much more severe than the described case.
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