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 D

Explanation

Choice A Reason: This is incorrect because administering a nitrate antihypertensive is not the first action, as it may cause a rapid drop in blood pressure and worsen the client's condition.

Choice B Reason: This is incorrect because obtaining the client's heart rate is not the first action, as it does not address the cause of autonomic dysreﬂexia or relieve the symptoms.

Choice C Reason: This is incorrect because assessing the client for bladder distention is not the first action, as it may take time and delay the treatment of autonomic dysreﬂexia.

Choice D Reason: This is correct because placing the client in a high-Fowler's position is the first action, as it lowers the blood pressure by promoting venous return and reducing cardiac preload.

A. Warm, ﬂushed skin B. Hyperactive deep tendon reﬂexes C. Bounding peripheral pulses D. Widened QRS complexes

Correct Answer is D

Explanation

Choice A Reason: This choice is incorrect because warm, ﬂushed skin is not a sign of respiratory acidosis. Warm, ﬂushed skin may indicate fever, infection, inﬂammation, or allergic reaction, but it does not reﬂect the acid-base imbalance in the blood.

Choice B Reason: This choice is incorrect because hyperactive deep tendon reﬂexes are not a sign of respiratory acidosis. Hyperactive deep tendon reﬂexes may indicate hypocalcemia, hyperthyroidism, or spinal cord injury, but they do not reﬂect the carbon dioxide level in the blood.

Choice C Reason: This choice is incorrect because bounding peripheral pulses are not a sign of respiratory acidosis. Bounding peripheral pulses may indicate increased cardiac output, anxiety, or hyperthyroidism, but they do not reﬂect the pH level in the blood.

Choice D Reason: This choice is correct because widened QRS complexes are a sign of respiratory acidosis. QRS complexes are the segments on an electrocardiogram (ECG) that represent the depolarization of the ventricles. A normal QRS complex duration is 0.06 to 0.10 seconds, and a widened QRS complex duration is more than 0.12 seconds. A widened QRS complex may indicate hyperkalemia, which is a common complication of kidney failure and respiratory acidosis. Hyperkalemia is a condition in which the serum potassium level is higher than normal (more than 5 mEq/L). It may cause cardiac arrhythmias, muscle weakness, or paralysis.

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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

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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