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 A
Explanation
Choice A rationale:
Serum creatinine level is a reliable indicator of kidney function.
Choice B rationale:
While it can indicate severe renal impairment, it doesn’t diagnose specific diseases.
Choice C rationale:
It doesn’t specifically test for medication interference.
Choice D rationale:
It’s the nurse’s role to provide this information, not defer to the doctor.
Correct Answer is C
Explanation
Choice A rationale:
Having a loss of peripheral vision is not a typical symptom of cataracts. This symptom is more associated with conditions like glaucoma.
Choice B rationale:
Loss of central vision is not a typical symptom of cataracts. This symptom is more associated with conditions like macular degeneration.
Choice C rationale:
Having a decreased ability to perceive colors is a common symptom of cataracts. Cataracts can cause vision to become cloudy or yellowed, affecting color perception.
Choice D rationale:
Seeing bright flashes of light and floaters are not typical symptoms of cataracts. These symptoms are more commonly associated with conditions like retinal detachment.
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