The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

Urine output of 0.5-1 mL/kg/hr

Serum sodium level 149 mEq/L. (normal 135-145)

Blood pressure 82/54

Heart rate 124 beats per minute

Answer and Explanation

The Correct Answer is A

A) Urine output of 0.5-1 mL/kg/hr:
This is a positive outcome during fluid resuscitation for burn patients. Adequate urine output is a key indicator of proper renal perfusion and fluid balance. A urine output of 0.5-1 mL/kg/hr is considered optimal for burn patients during the first 24-48 hours of resuscitation. It suggests that the kidneys are receiving sufficient blood flow and that the patient is responding appropriately to the fluids being administered.

B) Serum sodium level 149 mEq/L (normal 135-145):
A serum sodium level of 149 mEq/L is high and indicates hypernatremia, which is a common complication of excessive fluid resuscitation, particularly with the use of crystalloids. Hypernatremia can lead to cerebral edema, altered mental status, and other severe complications. Therefore, this finding would suggest improper fluid management and would not be considered a positive outcome.

C) Blood pressure 82/54:
A blood pressure of 82/54 is hypotensive, which is concerning in a burn patient. Hypotension indicates inadequate tissue perfusion, potentially leading to shock and organ failure. While low blood pressure may occur in the initial stages of resuscitation due to the rapid shifts in fluid, a sustained low blood pressure is not a positive outcome.

D) Heart rate 124 beats per minute:
A heart rate of 124 beats per minute is tachycardic and suggests that the patient is compensating for hypovolemia or inadequate circulatory volume, possibly due to insufficient fluid resuscitation. Although an elevated heart rate may occur as a compensatory mechanism in the initial stages of burn resuscitation, sustained tachycardia indicates ongoing volume depletion or inadequate perfusion and is not an ideal outcome.

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Correct Answer is D

Explanation

A) Chemical burns to the posterior neck, chest, and back:
Chemical burns primarily affect the skin and underlying tissues where the chemicals have come into contact. Although chemical burns can cause significant damage, particularly to the respiratory system if inhaled, chemical burns to the posterior neck, chest, and back would not typically require endotracheal intubation or tracheostomy unless there is evidence of inhalation injury or airway compromise.

B) Radiation burns to shoulder and bridge of nose:
Radiation burns, such as those from sunburn or therapeutic radiation, generally do not cause immediate airway compromise or respiratory distress unless the radiation exposure has affected the lungs or upper respiratory tract.

C) Electrical burns to the hands causing dysrhythmias:
Electrical burns can cause significant tissue damage, especially if there is a deep tissue injury and potential for electrical burns to the internal organs. They can lead to dysrhythmias, but these burns are more related to cardiac complications rather than direct airway injury. Endotracheal intubation may be required if there are signs of airway compromise or respiratory failure, but the primary concern with electrical burns would be cardiac monitoring and fluid resuscitation.

D) Thermal burns to the head, neck, face, and airway:
The upper airway (including the mouth, throat, and vocal cords) is particularly vulnerable to thermal injury from inhaling hot gases, smoke, or steam. This can lead to edema and airway obstruction, which can rapidly progress to respiratory failure. Endotracheal intubation or even a tracheostomy may be required to secure the airway and prevent suffocation. Inhalation injury is a significant concern in thermal burns involving the head, neck, and face.

A. Pneumonia B. Drowning C. Aspiration D. Sepsis E. Blood Transfusion

Correct Answer is ["D","E"]

Explanation

A) Pneumonia: Pneumonia is a direct cause of ARDS, as it involves direct inflammation and infection of the lung tissue, leading to impaired oxygen exchange and damage to the alveolar-capillary membrane. It results in fluid accumulation in the lungs, which is a key characteristic of ARDS.

B) Drowning: Drowning is another direct cause of ARDS. It involves the aspiration of water into the lungs, which directly damages lung tissue, causing pulmonary edema and impaired oxygenation.

C) Aspiration: Aspiration of food, liquid, or vomit into the lungs is also a direct cause of ARDS. The aspirated material can lead to chemical pneumonia, bacterial infection, and inflammation of the lungs, which in turn causes ARDS.

D) Sepsis: Sepsis is an indirect cause of ARDS. It can lead to widespread inflammation throughout the body, including the lungs, through the release of inflammatory mediators (cytokines, interleukins, etc.). These systemic inflammatory responses can increase capillary permeability in the lungs, causing fluid to leak into the alveoli, which leads to ARDS.

E) Blood Transfusion: Blood transfusion, particularly when associated with transfusion-related acute lung injury (TRALI), is an indirect cause of ARDS. TRALI is a serious complication that can result from receiving blood products, where the transfused blood causes an immune response leading to pulmonary damage. It indirectly triggers inflammation and fluid buildup in the lungs, contributing to ARDS.

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The nurse is caring for patient with severe, major burns who is receiving fluid resuscitation per protocol. Which of the following assessments indicate positive outcome?

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Naxlex Comprehensive Predictor Exams

The nurse identifies that which patient with a burn injury most likely require endotracheal intubation or tracheostomy tube? The patient with:

Correct Answer is D

Explanation

What does the nurse identify as INDIRECT cause of acute respiratory distress syndrome (ARDS) SELECT ALL THAT APPLY

Correct Answer is ["D","E"]

Explanation

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