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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["125"]
Explanation
Step 1: Determine the total time required to infuse 40 mEq at a rate of 10 mEq/hr.
40 mEq ÷ 10 mEq/hr = 4 hours
Result: 4 hours
Step 2: Determine the infusion rate in mL/hr.
500 mL ÷ 4 hours = 125 mL/hr
Result: 125 mL/hr
The nurse should set the IV pump to deliver 125 mL/hr.
Correct Answer is D
Explanation
Choice A Reason: Cause of the burn is not the nurse's priority when assessing the severity of the client's burns. The cause of the burn may indicate the type and duration of exposure, such as thermal, chemical, electrical, or radiation, which can affect the depth and extent of injury. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice B Reason: Age of the client is not the nurse's priority when assessing the severity of the client's burns. The age of the client may influence the response to burn injury, such as healing time, infection risk, and fluid requirements.
However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice C Reason: Associated medical history is not the nurse's priority when assessing the severity of the client's burns. The associated medical history may affect the outcome and prognosis of burn injury, such as pre-existing conditions, medications, or allergies. However, these factors are secondary to ensuring adequate oxygenation and ventilation.
Choice D Reason: Location of the burn is the nurse's priority when assessing the severity of the client's burns. The location of the burn can indicate the potential for life-threatening complications, such as airway obstruction, inhalation injury, or impaired circulation. The nurse should assess for signs and symptoms of respiratory distress, such as stridor, wheezes, or cyanosis, and prepare for endotracheal intubation if needed. The nurse should also monitor for signs and symptoms of compartment syndrome, such as pain, pallor, paresthesia, pulselessness, or paralysis, and report any findings to the provider. The location of the burn can also affect the functional and cosmetic outcomes, such as vision loss, facial disfigurement, or joint contractures. The nurse should provide appropriate wound care, pain management, and rehabilitation as prescribed. Assessing for location of burn is essential to prevent further injury and preserve vital functions.
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