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 D
Explanation
A. Increase activity to promote mobility. While moderate activity is beneficial, excessive activity can exacerbate symptoms of SLE.
B. Increase exposure to the sun to increase vitamin D absorption. Sun exposure can trigger lupus flares, so it should be minimized.
C. Increase sodium consumption. Increased sodium intake is not recommended as it can lead to hypertension, a common concern in SLE patients.
D. Maintain a balance between rest and activity. Balancing rest and activity helps manage fatigue and prevent symptom exacerbation in SLE.
Correct Answer is D
Explanation
A. Meeting patient goals. While meeting patient goals is important, it is the result of care and does not directly build trust or address psychosocial needs on its own.
B. Developing a care plan. Developing a care plan is essential for organizing patient care, but it is a behind-the-scenes activity that the patient may not directly perceive as building trust or addressing psychosocial needs.
C. Implementing nurse orders. Implementing nurse orders is part of routine care delivery but does not specifically build trust or address psychosocial needs.
D. Patient education. Patient education helps build trust by empowering patients with knowledge about their condition and care plan. It encourages patients to have confidence in the care they are receiving and addresses their psychosocial needs by reducing anxiety and uncertainty.
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