The nurse is caring for a 26-year-old patient who was burned 72 hours ago. The patient has partial-thickness burns to 24% of the body surface area and begins to excrete large amounts of urine. Which action should the nurse take?
Monitor for signs of seizure activity.
Increase the IV rate and monitor for burn shock.
Raise the foot of the bed and apply blankets.
Assess for signs of fluid overload.
The Correct Answer is D
A. Monitor for signs of seizure activity: Seizure activity is not directly related to the condition described.
B. Increase the IV rate and monitor for burn shock: Increasing the IV rate could exacerbate fluid overload; burn shock is more of a concern in the initial hours post-burn.
C. Raise the foot of the bed and apply blankets. This is not relevant to addressing the issue of large urine output.
D. Assess for signs of fluid overload: After the initial fluid resuscitation phase, large urine output may indicate that fluid is being mobilized from the tissues back into the vascular system, potentially leading to fluid overload.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "Usually in about 2 hours, but the effects will return in 2 to 3 days." The acute effects of amphetamines typically last longer than 2 hours, and there's no consistent return of effects after 2 to 3 days.
B. "She will snap out of it in a day or two." This response is not accurate and lacks sensitivity. The effects of an overdose need careful medical monitoring and do not simply "snap out."
C. "Usually in 8 to 10 hours." The acute effects of an amphetamine overdose generally subside within 8 to 10 hours, depending on the amount taken and individual metabolism.
D. "The manifestations may be permanent." While severe complications from an overdose can be long-lasting, the acute effects typically subside within hours, not permanently.
Correct Answer is A
Explanation
A. Anxiety related to uncertainty of the events of the test: Addressing the patient's anxiety and providing information about the procedure can help reduce fear and improve cooperation.
B. Deficient knowledge related to lack of information regarding the procedure: While providing information is important, the immediate emotional response (anxiety) takes priority as it can impact the patient's experience of the procedure.
C. Disturbed thought process related to confusion: While disturbed thought processes are relevant, they are not the primary concern pre-procedure.
D. Disturbed thought process related to temporary memory loss: Temporary memory loss can occur post-ECT, but addressing pre-procedure anxiety is a more immediate priority.
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