A nurse is monitoring a client who was admitted 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?
Heart rate
Blood pressure
Weight
Urine output
The Correct Answer is A
Choice A rationale:
A decrease in heart rate is an indication of adequate fluid replacement. As fluid volume is restored, the heart does not have to work as hard to pump blood, so the heart rate decreases.
Choice B rationale:
Blood pressure is not a reliable indicator of fluid volume status. It can be influenced by many factors, including pain, anxiety, and medications.
Choice C rationale:
Weight is not a reliable indicator of fluid volume status in the short term. It can take several days for changes in fluid volume to be reflected in weight.
Choice D rationale:
Urine output is a good indicator of kidney function, but it is not a reliable indicator of fluid volume status. Many factors can influence urine output, including kidney function, fluid intake, and medications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Examining feet daily is important for preventing complications related to peripheral neuropathy, not retinopathy or nephropathy.
Choice B rationale:
Maintaining stable blood glucose levels can help prevent microvascular complications such as retinopathy and nephropathy.
Choice C rationale:
Annual eye examinations are important, but they do not prevent retinopathy.
Choice D rationale:
Wearing compression stockings daily is not directly related to preventing retinopathy or nephropathy.
Correct Answer is A
Explanation
Choice A rationale:
Dextrose 10% in water can be used as a temporary replacement for TPN to prevent hypoglycemia until the TPN solution is available.
Choice B rationale:
3% sodium chloride is a hypertonic solution and is not typically used as a replacement for TPN.
Choice C rationale:
0.9% sodium chloride, or normal saline, does not provide the necessary nutrients that are included in TPN.
Choice D rationale:
Lactated Ringer’s is used for fluid resuscitation and does not provide the necessary nutrients that are included in TPN.
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