A patient has been rescued from a house fire and admitted to the burn unit with deep dermal, partial thickness (second degree) burns over approximately one-third of the back and upper thighs.
The nurse begins administration of prescribed crystalloid fluids for the first 24-hours following the burn incident.
What physiological response is promoted by the administration of the fluids?

Fluid resuscitation due to capillary leaking.

Restoration of electrolyte balance.

Replacement of insensible water loss.

Extension of plasma until blood is available.

Answer and Explanation

The Correct Answer is A

Choice A rationale

The administration of crystalloid fluids in the first 24 hours following a burn incident promotes fluid resuscitation due to capillary leaking. In the aftermath of a burn, there is a disruption of the normal fluid balance in the body, leading to increased capillary permeability and fluid shifts. This can result in a condition known as burn shock, characterized by decreased blood volume and inadequate tissue perfusion. The administration of crystalloid fluids helps to restore intravascular volume, improve tissue perfusion, and prevent burn shock. It also minimizes burn wound conversion and reduces the incidences of post-burn renal failure, life-threatening electrolyte disturbances, and mortality.

Choice B rationale

While restoration of electrolyte balance is an important aspect of burn management, it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Electrolyte imbalances in burn patients are usually a result of the systemic inflammatory response, fluid shifts, and renal dysfunction that can occur after a burn. These imbalances are typically managed through careful monitoring and specific electrolyte replacement therapies, rather than through the initial administration of crystalloid fluids.

Choice C rationale

Replacement of insensible water loss is another important aspect of burn management, but it is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. Insensible water loss occurs through evaporation from the burn wound surface and can be significant in burn patients. However, this is typically managed through the maintenance of a humidified environment and specific fluid replacement strategies, rather than through the initial administration of crystalloid fluids.

Choice D rationale

Extension of plasma until blood is available is not the primary physiological response promoted by the administration of crystalloid fluids in the immediate aftermath of a burn. While blood products may be required in the management of severe burns, particularly if there is significant blood loss or hemodynamic instability, the initial focus of fluid resuscitation in burn patients is on the administration of crystalloid solutions to restore intravascular volume and improve tissue perfusion.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","F"]

Explanation

A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

A. I should have taken some allergy medications before going on the hike. B. I have been very stressed out lately and should work on stress management. C. I should have taken an extra dose of fluticasone-salmeterol. D. I should have eaten a snack halfway through the hike. E. My friend smoked cigarettes during the hike.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Correct Answer is ["A","B","C","D","F"]

Explanation

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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