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:
Potassium 2.3 mEq/L is below the normal range of 3.5 to 5.0 mEq/L1. Hydrochlorothiazide, a diuretic, can cause hypokalemia, which is a low level of potassium.
Choice B rationale:
Chloride 99 mEq/L is within the normal range of 96 to 106 mEq/L2, so it’s not a concern.
Choice C rationale:
Sodium 136 mEq/L is within the normal range of 135 to 145 mEq/L3, so it’s not a concern.
Choice D rationale:
Calcium 10 mg/dL is within the normal range of 8.6 to 10.2 mg/dL4, so it’s not a concern.
Correct Answer is B
Explanation
Choice A rationale:
Placing the client back in bed during a seizure could potentially cause injury. The priority is to protect the client from harm during the seizure.
Choice B rationale:
Placing the client on his side, specifically the recovery position, helps keep the airway clear and prevents aspiration.
Choice C rationale:
Holding the client’s arms and legs from moving could cause injury. It’s important to let the seizure take its course while protecting the client from harm.
Choice D rationale:
Inserting a tongue blade or any other object in the client’s mouth during a seizure is not recommended. It could cause injury to the client or the nurse.
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