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 ﬂuid overload is a condition of excess ﬂuid volume in the body. A client who has ﬂuid overload is more likely to have a high CVP, which indicates increased pressure in the right atrium and vena cava.

Choice B Reason: This is incorrect because an intracardiac shunt is a condition of abnormal blood ﬂow between the chambers of the heart. A client who has an intracardiac shunt may have a normal or high CVP, depending on the direction and magnitude of the shunt.

Choice C Reason: This is correct because hypovolemia is a condition of low ﬂuid volume in the body. A client who has hypovolemia is more likely to have a low CVP, which indicates decreased pressure in the right atrium and vena cava.

Choice D Reason: This is incorrect because left ventricular failure is a condition of impaired pumping function of the left ventricle. A client who has left ventricular failure may have a normal or high CVP, depending on the degree of backward failure and pulmonary congestion.

A. Respiratory status B. Temperature C. Intracranial pressure D. Serum electrolytes

Correct Answer is A

Explanation

The correct answer is a. Respiratory status.

Choice A: Respiratory Status

Reason: After the evacuation of a subdural hematoma, monitoring the respiratory status is crucial. This is because changes in respiratory patterns can indicate increased intracranial pressure (ICP) or brainstem compression, which are life-threatening conditions. Ensuring that the airway is clear and that the patient is breathing adequately is the top priority. Normal respiratory rate for adults is 12-20 breaths per minute.

Choice B: Temperature

Reason: While monitoring temperature is important to detect infections or other complications, it is not the immediate priority in the acute postoperative period following a subdural hematoma evacuation. Fever can indicate infection, but it is less likely to cause immediate life-threatening complications compared to respiratory issues.

Choice C: Intracranial Pressure

Reason: Monitoring intracranial pressure (ICP) is very important in patients with brain injuries. Normal ICP ranges from 5-15 mmHg. However, changes in respiratory status can be an early indicator of increased ICP. Therefore, while ICP monitoring is critical, ensuring the patient’s respiratory status is stable takes precedence.

Choice D: Serum Electrolytes

Reason: Serum electrolytes are important to monitor for overall metabolic stability and to detect imbalances that could affect neurological function. Normal ranges for key electrolytes are: Sodium (135-145 mEq/L), Potassium (3.5-4.5 mEq/L), and Chloride (80-100 mEq/L). However, these are not the immediate priority in the acute phase following surgery compared to respiratory status.

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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

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