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:
Insulin glargine is a long-acting insulin and is not used for the immediate treatment of diabetic ketoacidosis (DKA).
Choice B rationale:
Insulin detemir is also a long-acting insulin and is not used for the immediate treatment of DKA.
Choice C rationale:
Regular insulin is a short-acting insulin and is used for the immediate treatment of DKA.
Choice D rationale:
NPH insulin is an intermediate-acting insulin and is not used for the immediate treatment of DKA.

A. Determine if the client needs to continue IV therapy. B. Initiate a new IV line in the other extremity. C. Discontinue the existing IV line. D. Apply a hot pack to the irritated site.

Correct Answer is C

Explanation

Choice A rationale:
Determining if the client needs to continue IV therapy is important, but it is not the first action the nurse should take. The nurse should first address the immediate problem, which is the irritated IV site.
Choice B rationale:
Initiating a new IV line in the other extremity is necessary, but not the first action. The nurse should first discontinue the existing IV line to prevent further irritation or infection.
Choice C rationale:
The nurse should first discontinue the existing IV line. This is because the symptoms indicate that the client might have developed phlebitis, an inflammation of the vein, which requires immediate discontinuation of the IV line.
Choice D rationale:
Applying a hot pack to the irritated site can help reduce inflammation and discomfort, but it is not the first action. The nurse should first discontinue the IV line to prevent further complications.

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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

Correct Answer is C

Explanation

While assessing a client who is receiving continuous IV therapy via his left forearm, a nurse notes that the site is red, swollen, and painful and that the surrounding tissues are hard. Which of the following actions should the nurse take first?

Correct Answer is C

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?