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 B
Explanation
A. Trim the fingernails short to prevent skin damage from scratching. While this is good advice to prevent further skin damage, it does not directly address the itching.
B. Use cool, wet dressings and baths to promote vasoconstriction. Cool, wet dressings and baths can help soothe itching and reduce inflammation by promoting vasoconstriction.
C. Expose the areas to the sun to promote drying and healing of the lesions. Sun exposure can worsen irritation and is not recommended for treating contact dermatitis.
D. Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation. While this can prevent further irritation, it does not directly manage the itching.
Correct Answer is D
Explanation
A. Every 6 months. Semi-annual screenings may be necessary for certain conditions or if there are ongoing health issues, but generally, an annual check-up is sufficient for preventive health.
B. Every 3 years. This interval is too long for preventive health screenings in older adults, who are at higher risk for various health conditions.
C. Every 2 years. This interval may be appropriate for certain screenings, but annual check-ups are recommended to ensure timely detection and management of health issues.
D. Every year. Annual health screenings are recommended for older adults to monitor for chronic conditions, update vaccinations, and promote overall health.
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