The medical-surgical nurse is caring for a 55-year-old female patient after surgery. The patient's respiratory rate has increased from 12 to 22 breaths/min, and the pulse rate has increased from 86 to 110 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best?

Assess the patient's tissue perfusion further.

Ask if the patient needs pain medication.

Document the findings in the patient's chart.

Increase the rate of the patient's IV infusion.

Answer and Explanation

The Correct Answer is A

The increased respiratory rate and pulse rate can be indicators of physiological changes or potential complications in the patient's condition. These changes may suggest alterations in tissue perfusion or other underlying issues that require further assessment.
Assessing the patient's tissue perfusion includes evaluating additional vital signs, such as blood pressure, oxygen saturation, and capillary refill time. Assessing skin color, temperature, and moisture, as well as peripheral pulses, can also provide important information regarding tissue perfusion.
B. Pain medication (option B) is incorrect because the increased respiratory and pulse rates could also indicate other factors that require assessment before administering pain medication.
C. Documenting the findings in the patient's chart (option C) is incorrect because it should not be the primary action at this point. Assessing the patient's condition and determining appropriate interventions take priority.
D. Increasing the rate of the patient's IV infusion (option D) is incorrect because may not be the most appropriate action without further assessment. The patient's increased respiratory and pulse rates may not necessarily be related to hydration status, and it is important to assess the patient comprehensively before making changes to the IV infusion rate.
Therefore, the best action by the nurse in this situation is to further assess the patient's tissue perfusion to gather more information and determine the appropriate course of action.

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Correct Answer is ["21"]

Explanation

flow rate for an infusion= (Volume in mL * Drop factor) / Time in minutes.

volume of the infusion bag is 250 mL, the drop factor is 10 gtts/mL, and the time is 2 hours, which is 120 minutes.

(250 mL * 10 gtts/mL) / 120 minutes = 2500 gtts / 120 minutes ≈ 20.83 gtts/minute. Therefore, the nurse should run the infusion at a rate of approximately 21 drops per minute to deliver 1 unit of packed red blood cells over the 2-hour period.

Correct Answer is ["9000"]

Explanation

4 mL × body weight in kg × percentage of burn = total fluid volume for the first 24 hours Then, divide the total fluid volume by 2 to determine the fluid volume for the first 8 hours.

In this case, the patient weighs 90 kg and has a 50% burn injury.

4 mL × 90 kg × 50% = 18,000 mL (total fluid volume for 24 hours)

18,000 mL / 2 = 9,000 mL (fluid volume for the first 8 hours)

Therefore, the nurse would infuse the intravenous fluid resuscitation at a rate of 9,000 mL over the first 8 hours.

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The medical-surgical nurse is caring for a 55-year-old female patient after surgery. The patient's respiratory rate has increased from 12 to 22 breaths/min, and the pulse rate has increased from 86 to 110 beats/min since the patient was last assessed 4 hours ago. What action by the nurse is best?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["21"]

Explanation

An emergency room nurse cares for a patient admitted with a 50% burn injury. The patient weighs 90 kg. Using the Parkland formula, calculate the rate (1st 8 hrs.) at which the nurse would infuse intravenous fluid resuscitation. (Record your answer using a whole number.)

Correct Answer is ["9000"]

Explanation

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