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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?

A.

Heart rate

B.

Blood pressure

C.

Weight

D.

Urine output

Answer and Explanation

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.
 


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Related Questions

Correct Answer is B

Explanation

Choice A rationale:
Notifying the nurse manager is important, but it’s not the priority action.
Choice B rationale:
Monitoring the client for hypoglycemia is the priority because the nurse administered an excessive insulin dose.
Choice C rationale:
Completing an incident report is necessary, but it’s not the priority action.
Choice D rationale:
Giving the client 15 to 20 g of carbohydrate might be necessary if the client shows signs of hypoglycemia.

Correct Answer is B

Explanation

Choice A rationale:
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
Choice B rationale:
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
Choice C rationale:
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
Choice D rationale:
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.

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