A nurse is monitoring the ﬂuid replacement of a client who has sustained burns. The nurse should administer which of the following ﬂuids in the first 24 hr following a burn injury?

Dextrose 5% in 0.9% sodium chloride

Dextrose 5% in water

0.9% sodium chloride

Lactated Ringer's

Answer and Explanation

The Correct Answer is D

Choice A Reason: This is incorrect because dextrose 5% in 0.9% sodium chloride is a hypertonic solution that can cause ﬂuid overload and pulmonary edema in a client who has burns.

Choice B Reason: This is incorrect because dextrose 5% in water is a hypotonic solution that can cause ﬂuid shifts from the intravascular space to the interstitial space, resulting in hypovolemia and hypotension in a client who has burns.

Choice C Reason: This is incorrect because 0.9% sodium chloride is an isotonic solution that can cause hypernatremia and hyperchloremia in a client who has burns, as the ﬂuid loss from burns is greater than the sodium loss.

Choice D Reason: This is correct because lactated Ringer's is an isotonic solution that contains electrolytes similar to plasma, such as sodium, potassium, calcium, and chloride. It also contains lactate, which is converted to bicarbonate in the liver and helps correct the metabolic acidosis that occurs in a client who has burns.

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Correct Answer is C

Explanation

Choice A Reason: This choice is incorrect because slowing the rate to 50 mL/hr may not be enough to prevent cerebral edema, which is a common complication of head injury. Cerebral edema is a swelling of the brain tissue due to increased ﬂuid accumulation. It can cause increased intracranial pressure (ICP), which can lead to brain damage or death. Therefore, the nurse should limit the ﬂuid intake of the client with head injury to avoid worsening the condition.

Choice B Reason: This choice is incorrect because increasing the rate to 250 mL/hr may cause ﬂuid overload, which can also increase the ICP and worsen the cerebral edema. Fluid overload is a condition in which the body has too much ﬂuid, which can impair the function of the heart, lungs, and kidneys. Therefore, the nurse should avoid giving too much ﬂuid to the client with head injury.

Choice C Reason: This choice is correct because slowing the rate to 20 mL/hr may help to maintain adequate hydration and electrolyte balance, while preventing ﬂuid overload and cerebral edema. This is a conservative approach that can be used until the client's neurological status and ICP are assessed and monitored.

Choice D Reason: This choice is incorrect because continuing the rate at 125 mL/hr may not be appropriate for the client with head injury, depending on their individual needs and condition. The nurse should adjust the ﬂuid rate according to the client's vital signs, urine output, serum osmolality, and ICP. Therefore, the nurse should not assume that this rate is optimal for the client without further evaluation.

A. Right ventricular failure B. Fluid volume deficit C. Mitral regurgitation D. Afterload reduction

Correct Answer is C

Explanation

Choice A Reason: This is incorrect because right ventricular failure would cause an increase in right atrial pressure and right ventricular end-diastolic pressure, but not in PAWP, which reﬂects left atrial pressure and left ventricular end- diastolic pressure.

Choice B Reason: This is incorrect because ﬂuid volume deficit would cause a decrease in PAWP, as there would be less blood volume in the pulmonary circulation.

Choice C Reason: This is correct because mitral regurgitation would cause an increase in PAWP, as the blood would back up into the left atrium and pulmonary veins due to the incompetent mitral valve.

Choice D Reason: This is incorrect because afterload reduction would cause a decrease in PAWP, as there would be less resistance to the left ventricular ejection and less blood volume in the pulmonary circulation.

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A nurse is monitoring the ﬂuid replacement of a client who has sustained burns. The nurse should administer which of the following ﬂuids in the first 24 hr following a burn injury?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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