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

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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Correct Answer is C

Explanation

Choice A rationale:
Sensitivity to light is a common postoperative symptom after cataract surgery.
Choice B rationale:
Difficulty with depth perception is expected when one eye is patched.
Choice C rationale:
Severe pain is not a normal postoperative symptom and should be reported to the provider.
Choice D rationale:
Itching is a common postoperative symptom after cataract surgery.

A. Apply a cold pack to the client's upper arm. B. Measure the circumference of both upper arms. C. Remove the PICC line. D. Notify the provider who inserted the PICC line.

Correct Answer is B

Explanation

Choice A rationale:
Applying a cold pack to the client’s upper arm would not be the first action to take. It may help reduce swelling, but it does not address the underlying issue.
Choice B rationale:
Measuring the circumference of both upper arms is the correct first action. This will provide objective data about the extent of the swelling, which can then be reported to the healthcare provider.
Choice C rationale:
Removing the PICC line is not the first action to take. This should only be done under the direction of a healthcare provider.
Choice D rationale:
Notifying the provider who inserted the PICC line is important, but it should be done after gathering all necessary data, including measuring the arm circumference.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following cataract surgery. Which of the following comments from the client should the nurse report to the client's provider?

Correct Answer is C

Explanation

A nurse is caring for a client who is receiving total parenteral nutrition via a peripherally inserted central catheter (PICC). When assessing the client, the nurse notes swelling of the client's arm above the PICC insertion site. Which of the following actions should the nurse take first?

Correct Answer is B

Explanation

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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?