A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV ﬂuid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate ﬂuid replacement?

Urine output

Heart rate

Weight

Blood pressure

Answer and Explanation

The Correct Answer is B

Choice A Reason: Urine output is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, urine output should increase as the ﬂuid therapy restores the renal perfusion and function. The nurse should monitor the urine output and ensure that it is at least 0.5 mL/kg/hr for adults and 1 mL/kg/hr for children.

Choice B Reason: Heart rate is a finding that should decrease with adequate ﬂuid replacement. A high heart rate is a sign of hypovolemia, which occurs when the burn injury causes ﬂuid loss from the intravascular space. The nurse should monitor the heart rate and expect it to decrease as the ﬂuid therapy replenishes the blood volume and improves the cardiac output.

Choice C Reason: Weight is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, weight may increase as the ﬂuid therapy restores the hydration status and corrects the ﬂuid deficit. The nurse should monitor the weight and compare it with the pre-burn weight to evaluate the ﬂuid balance.

Choice D Reason: Blood pressure is not a finding that should decrease with adequate ﬂuid replacement. On the contrary, blood pressure may increase as the ﬂuid therapy restores the vascular tone and improves the tissue perfusion. The nurse should monitor the blood pressure and expect it to increase as the ﬂuid therapy compensates for the ﬂuid loss.

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Correct Answer is C

Explanation

Choice A Reason: This is incorrect because clamping the client's chest tube can cause a tension pneumothorax, which is a life-threatening condition that requires immediate intervention.

Choice B Reason: This is incorrect because increasing the client's wall suction can cause excessive negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

Choice C Reason: This is correct because repositioning the client can help relieve chest burning, which may be caused by irritation of the intercostal nerves by the chest tube or by air trapping in the pleural space.

Choice D Reason: This is incorrect because stripping the client's chest tube can create high negative pressure in the pleural space, which can damage the lung tissue and impair ventilation.

A. Continue to monitor the client's respiratory status. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Check the tubing connections for leaks.

Correct Answer is A

Explanation

Choice A Reason: This choice is correct because slow, steady bubbling in the suction control chamber indicates that the suction is working properly and maintaining a negative pressure in the pleural space. The nurse should continue to monitor the client's respiratory status, such as breath sounds, oxygen saturation, and respiratory rate, to assess the eﬀectiveness of the chest drainage system.

Choice B Reason: This choice is incorrect because checking the suction control outlet on the wall is not necessary unless there is no bubbling in the suction control chamber, which would indicate a problem with the suction source or setting. The nurse should ensure that the suction control outlet is set at the prescribed level, usually between 10 and 20 cm H2O.

Choice C Reason: This choice is incorrect because clamping the chest tube is not indicated unless there is a leak in the system or the chest drainage unit needs to be changed. Clamping the chest tube may cause a buildup of air or ﬂuid in the pleural space, which can lead to tension pneumothorax or pleural eﬀusion.

Choice D Reason: This choice is incorrect because checking the tubing connections for leaks is not necessary unless there is continuous bubbling in the water seal chamber, which would indicate an air leak in the system. The nurse should ensure that all tubing connections are tight and secure, and tape any loose connections.

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A nurse is monitoring a client who was admited with a severe burn injury and is receiving IV ﬂuid resuscitation therapy. The nurse should identify a decrease in which of the following findings as an indication of adequate ﬂuid replacement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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